PEOPLE'S HEALTH ASSEMBLY HEALTH IN THE ERA OF GLOBALISATION FROM VICTIMS TO PROTAGONISTS
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- Title
- PEOPLE'S HEALTH ASSEMBLY HEALTH IN THE ERA OF GLOBALISATION FROM VICTIMS TO PROTAGONISTS
- extracted text
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from
victims -fo protagonists
A discussion paper
prepared by the
PHA drafting group
■
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his paper aims to provide an overview of the
current health situation, its major determi
nants and serves as a framework of analysis
of the PHA.
T
An analysis of the health situation and its determinants
is a story of inequality and unequal distribution.
Although the last 50 years have witnessed
improvements in life expectancy, declining mortality
rates (especially infant mortality), and lower fertility
rates in most countries, these numbers tend to hide the
real disparities between and within countries, between
social classes and between men and women.
Despite some gains, we have not made substantive improvements in the main underlying
determinants of health. Levels of poverty remain unacceptably high, natural resources have been
drastically depleted and there has been further degradation of the global environment, in the longerterm threatening everybody's health. Although the world produces more than enough food to feed
its entire population adequately and medical technology has made many advances, these benefits
are unevenly distributed. Wealth and knowledge are increasingly concentrated in First World
countries and the gap between the have and the have-nots continues to widen in all countries. At the
core of this is a central human rights and social justice issue.
To ensure health, peoples' basic needs for food, water, sanitation, housing, health services, education,
employment and security must be met. To enjoy more than just physical health, people need selfesteem; they need a sense of purpose, meaning and belonging. Healthy societies require a balance
between individual freedom and responsibility. Love, culture of compassion, care and respect for life
and spirituality are as important to the well-being of individuals, communities and nations as is the
economy.
The PHA is founded on the belief that together we can build a better world, and that organised
grassroots action can bring about positive social change. Action for change needs to be grounded on
a sound assessment—or 'situational analysis'—of the current reality. Such a collective analysis needs
to explore the immediate, underlying and basic causes of ill health and how these relate to the
interconnected crises of our times.
he most significant determinants of health in the world today are economic and political
factors that have colonial roots. Who has control over resources and decision-making, and
who has the power over whom, determines the way countries and the world are organised
and ruled. This impacts on the health status of people and the way health services are organised.
Most of the underlying and basic causes of ill health can be found here. From a health point of view,
the current trend towards economic globalisation, the lack of equity and distributive justice
aggravates the growing health crisis and widens the growing inequality gap.
T
Financial institutions such as the World Bank and the International Monetary Fund have been major
influences in determining the current model of development. They have universally prescribed
structural adjustment programmes (SAPs), which have cut employment and investment in the social
sectors, and removed protection to local industries, barriers to outflow of funds and labour
regulations. These programmes have had important consequences for the level of investment and
development of the health services as well as for the major determinants of health.
Health in the Era of Globalisation
1
new internationalist, august 1996
Not only has the gap between the rich and the poor widened
dramatically in recent decades, but globalisation has aggravated the
hardships of the disadvantaged millions. A host of laws, policies,
and trade agreements have been introduced, which advance the
planetary reach of TNCs and speculative investors. At the same time
the rights and self-determination of the poor and relatively
powerless peoples and nations are undermined.
New international organisations such as the WTO are increasing
their influence, through various agreements, and having an adverse
impact on health, food security and the environment. The TradeRelated Intellectual Property Rights (TRIPs) regime that, among other things, allows patenting of
seeds will pose a threat to genetic resources, sustainable agriculture, food security and the well-being
of fanners. Increasing patent protection will lead to increasing prices and reduced access to medi
cines, which will continue to be under monopoly control.
TNCs are promoting and dumping harmful products, processes and technologies such as tobacco,
asbestos, pesticides, dioxin, genetically engineered foods and seeds, and toxic waste. In particular,
they are releasing toxic, chemical and nuclear materials in Third World countries where they benefit
from weak governments and weak prohibitive legislation.
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s a result of these economic and political factors, there is increasing erosion of the social fabric
of societies, institutions, communities and families. One important trend resulting from the
•r Xcurrent global socio-economic development model is the weakening of national public institu
tions with forced rapid privatisation of services and decreased government control and accountabil
ity. Other traditional institutions, such as political parties and trade unions, are under increasing
stress. Trade unions are under threat of losing their constituencies and the confidence of workers.
This is mainly as a result of the current trend towards individual, productivity-oriented labour
relations, which do not foster workers' organisations and in many instances represses them.
Expansion of trade does not always mean more employment and better wages. Thus unemployment
and under-employment have sharply risen all over the world, straining the social fabric. Adverse
socio-economic conditions have altered traditional family structures all over the world.
The dislocation of populations due to migration for economic, political, and ethnic conflicts has a
direct influence on the health and well-being of millions of people.
We are currently also witnessing a global environmental crisis taking varied forms. The environmen
tal crisis is a crisis both of nature and of justice. Although the growing population of the Third World
is often blamed for the destruction of the environment, the industrial societies in the North and the
elites of the South are in fact the major culprits.
Our current environment and health crisis is associated
with the following:
88 The misleading view of progress and develop
ment as a universal, linear pattern of societal
change where different societies all take part in
the same race towards industrialisation and
ever-increasing wealth;
88 The notion of nature as an inert, mechanical
construction, existing only to be extracted and
exploited for human short-term benefit;
88 The failure of economics to base its theories in an
environmental context and to recognise ecologi
cal constraints;
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People’s Health Assembly
DObimoM
MILL BE DSEB
MStLY
\ USED TO
J ealth services today are inaccessible, unaffordable, inequitably distributed and inappropriate
in their emphasis and approach.
The 1978 Alma Ata Declaration, where comprehensive PHC was accepted and endorsed by all the
WHO and UNICEF member states, acknowledged that we need to act upon the underlying determi
nants of health, including those political economic factors that determine the health status of people
and population.
The economic policies of the 1980s led to the implementation of structural adjustment programmes
(SAPs), which increased the pressure on governments to de
crease their participation and commitment to universal
health services, limited the implementation of comprehen
sive PHC and promoted a wave of health care 're
forms'.
Severe cuts in national budgets for health resulted in
the deterioration and often the collapse of services
at many levels. Health Sector Reform has promoted
privatisation through such mechanisms as public
private partnerships and other approaches to
health-financing. These initiatives, together with the
lack of human and other resources in the under
funded public sector, have led to the rapid growth
of self-medication and a growth of the private
health sector. Large numbers of poor people have
been left with little or no access to any health care.
health for the millions, sept-oct, nov-dec 1997
Health care has been converted from a basic right into a product that can be sold or exchanged for
profit, resulting in an emphasis on the curative aspects of health at the expense of the preventive and
promotive dimensions of health care.
The institutional mechanisms needed to implement comprehensive PHC have been relatively ne
glected. Insufficient thought, resources-and energy have been allocated to important aspects of PHC,
such as the development of intersectoral action and community involvement.
This trend has been reinforced recently by new methodologies designed to promote cost-effective
ness in health. The development of DALYs (disability-adjusted life years) as an index to quantify the
burden of disease, and to cost the effectiveness of certain interventions, has resulted in the shift of
focus towards selected medical technologies at the expense of broader social interventions
he dimensions and complexity of the major problems affecting human and environmental
well-being today are hugely different from the situation that confronted past generations,
and far more difficult to challenge. There was a time when people in one part of the world
could come together and take a stand against unfairness or injustice at the local or even national level
and succeed. Today, the forces that threaten human and environmental well-being are increasingly
global, powerful, sophisticated and well coordinated.
T
New strategies are needed in the struggles for social change, to match the size and character of the
forces that we are dealing with.
As the worldwide crisis deepens and more and more people from all positions on the social spec
trum begin to realise that the current global economic system has lethal flaws, the groundswell for
change is gaining momentum.
There is an urgent need for a new, alternative vision of development—one that promotes human and
environmental well-being.
Health in the Era of Globalisation
People’s
Health Assembly
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WHO ARE WE?
he People's Health Assembly (PHA)
is an international, multisectoral
initiative aimed at bringing together
«E*3ffl individuals, groups, organisations, net
SSBKffl works and movements long involved in
the struggle for health. The idea started 15
years ago when peoples' organisation
realised that the World Health Assembly
of the World Health Organisation (WHO)
^DHg was unable to hear the people's voice and
a new forum was required. It is just now
«* m e1?
&gls that we are making this dream come true.
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We believe that health is a fundamental
human right that cannot be fulfilled
§>:$! without commitment to equity and social
justice. Our strength lies in numbers, and
&DBH in the sharing of creative, alternative ideas
for solutions. By creating a world-wide,
gess inter and multi-sectoral collective of
§® caring people and groups that includes
Rbkh people from all classes, castes, creeds,
§>:^i ages, gender, disabilities, ethnic origins
and nations, we strive to make our voices
heard.
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voices heard" in decisions affecting their health
and well-being. It is through collective action
that we will begin to change the unfair and
unsustainable top-down process of globalisation
- and its current negative impact on our overall
health and well-being.
The PHA provides an opportunity to present
people's perspectives on health. We invite you to
add to these ideas by putting forward your own
visions and dreams for a healthier society.
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HOW WE WILL
WHY THE NEED
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ACHIEVE OUR
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OBJECTIVES
Health Assembly?
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ndividuals and groups behind this
initiative believe that, through the
WBHS
&BBH
active participation of well-informed
^asg and concerned people, the fight for a
healthier, more just and sustainable world
Rife is possible.
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gaaS The prime objective of the PHA is to give
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a 'voice to the people and make their
he PHA process has three phases: pre
Assembly activities; a major international
Assembly event and post-Assembly activi
ties. Large numbers of people are already in
volved in the pre-Assembly activities and we
expect many more to get involved before De
cember 2000. In particular, we hope that people
will get actively involved in PHA activities in
their home countries.
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Please send your comments and feedback to Nadine Gasman
Fuente del Emperador 28, Tecamachalco C.P.53950. Mexico
fax: 525-2512518 or email: gasmanna@netmex.com
People’s Health Assembly
Pre-Assembly activities
These include local, regional and national dis
cussions focusing on the problems affecting
different people and communities, and their
struggles for change. People's experiences and
collective efforts to cope with, reform, or trans
form their current unhealthy situation will be
shared through the collection of stories and case
studies,. These experiences have fed into this
background paper and the associated discussion
papers. They will also provide a major input to
the formulation of a draft People's Charter for
Health (PCH). These experiences will be pre
sented and shared during the Assembly event.
The Assembly event
Scheduled for 4-8 December 2000, the Assembly
will be held at Gonoshasthaya Kendra (GK),
Savar, 37 km North of Dhaka, Bangladesh. We
expect around 600 participants, representing
people and their experiences from across the
globe.
The Assembly will be followed by a three-day
Follow-up Forum, where participants will have
further opportunities to share experiences,
network and meet with local community groups
in Bangladesh. Through these interactions, the
PHA will gather additional in-depth content.
Post-Assembly activities
The focus will be on disseminating, promoting
and seeking wider endorsement and implemen
tation of the People's Charter for Health and
other materials generated by the Assembly.
Advocacy and lobbying activities at the local,
national and international levels will be planned,
and mechanisms for further networking among
participating individuals and organisations will
be coordinated. The post-assembly activities will
form a long-term process of organisation and
action for change.
CURRENT
STRUCTURE OF
THE PHA
he PHA is currently coordinated by
representa-tives of eight convening interna
tional organisations (the Coordinating
Group) which represent groups and networks
actively involved in promoting health and
people's empowerment around the world.
Regional Coordinators have been appointed to
facilitate the work of the PHA, communicate and
foster participation in all regions. National
Preparatory Committees are working in some
countries.
T
There is a Secretariat in Savar, a Fundraising
group and an drafting group. There is continu
ous communication between all these groups.
HOW YOU CAN
PARTICIPATE
in -fho PHA
\ jl ■ e invite all people and organisations
u\l that subscribe to the concept of health
1 ’ asa human right and comprehensive
Primary Health Care to participate in the PHA
process.
There are several ways to participate:
3® We invite you to share stories and case
studies where you describe your health
problems and/or locally generated solutions
with the PHA.
I® You can organise meetings in your commu
nity or organisation (please contact the
regional or national coordinator for support
Health in the Era of Globalisation
and registration).
During the pre-assembly process you can
participate in planned PHA meetings at
local, regional or national level (please
contact the regional or national coordinator
for a list of upcoming meetings).
8>: You can participate in the development of
the PHA analytical background documents
(such as this paper) and the People's Char
ter for Health.
85 Some will be able to participate in the PHA
assembly in Savar, Bangladesh, 4-8 Decem
ber 2000. The number of participants will be
approximately 600. Our aim is to ensure
geographical spread and gender balance.
Preference will be given to people from the
grassroots level. To achieve this balance a
participatory selection process coordinated
at the regional level has been developed.
(For further information please contact your
regional or national coordinator).
85
Despite the relatively small number who will be
able to attend the December event, we hope
people will involve themselves in local, regional
or national activities, contribute to the PHA
documents and/or interact through our website
(www.pha2000.org).
Application forms for the December meeting
may be obtained from the PHA Secretariat or the
regional coordinators (see addresses below).
The preparation of the background documents,
the People's Charter for Health and the Action
Plan involves two key components:
K? the analysis of the causes of global and local
problems affecting people's health and well
being, and
13 a review of actions and alternatives people
have adopted to cope with or overcome
these problems.
We believe that, we will collectively produce
solid, hard-hitting background documents that
will provide some useful evidence to grass-root
organisations in our fight to improve people's
health and address the global health crisis.
The PHA drafting group has begun by drafting
an overview paper (which you are reading right
now) and five 'sectoral' papers on the topics: the
political economy of health, the social environ
ment and health, the physical environment and
health, the health sector and a paper describing
strategies and methods to improve communica
tion and learning. These papers can be used as
discussion materials at your local, regional and
national meetings.
We are also in the process of finalising a first
draft of the People's Charter for Health as a
basis for discussion. This Charter has as its
starting point the Alma Ata declaration, the
Patient Bill of Rights, Child Rights, the Conven
tion on the Elimination of All Forms of Discrimi
nation Against Women (CEDAW) and other
relevant people oriented declarations and
Charters. We hope you will send us your com
ments and inputs in time for the Assembly event
where the PCH will be endorsed.
We welcome feedback from concerned individu
als and groups on all the documents prepared
for the PHA, including this paper. Further, we
would welcome your submissions of concrete
action points that you would wish to see in
cluded in an overall action plan.
We urge you to help us identify suitable stories,
case studies, papers and audio-visual materials
that may illustrate some of the realities experi
enced by you and illustrate the points made in
these papers (or points not yet made!). Such
material is being gathered from all over the
world and will serve as a basis for deliberations
at the Assembly.
The rlr.ift background documents may be obtained from the
PHA Secretarial, r.on'r.hasthaya Kendra, PO Mirzanagar, Savar, 1344-Dhaka, Bangladesh.
E-mail; pha<x-C©pha2fXXJ.org or downloaded from wwwjaha2000,org
People’s Health Assembly
INTRODUCTION
he need for the 'democratisation of global decisions' is critical as we move into the new
century. Global policies affecting our present and future well-being are made by few
power-ful institutions like the World Trade Organisation (WTO), the World Bank (WB)
and the International Monetary Fund (IMF), together with the transnational corporations
(TNC) and the Northern and Southern governments supporting globalisation. These 'power
cliques' of the global economy are pushing globalisation at the cost of people's lives and the
deterioration of the environment.
T
The resulting gap between rich and poor, both between and within countries, has led to
deepening poverty, falling real wages, unemployment, deterioration of health, increased
disease and disability, despair and a global epidemic of crime, violence, disease, disability
and despair. While some people lead lives of over-consumption that damage their health
and endanger the planet's ecosystems, millions suffer from hunger and deprivation. This
unfair global socio-economic system is as unsustainable as it is inequitable. The ideology of
'growth at any cost' is leading, at an accelerated pace, to the disintegration of our social
fabric and the destruction of the environment.
Despite this grim scenario, there is a myriad of positive examples of individuals and groups
from all over the world, coming together to fight injustices and seek alternative solutions.
While these movements are still in their infancy, they are beginning to threaten established
power structures. In all the diversity of the causes they represent—health, agriculture,
education, environment, human rights, disarmament, gender or ethnic equality—these
popular movements are forming networks and increasingly discovering the common roots
of their sectoral problems recognising the inter linkages and alternatives of action they can
share and support.
Health, which in its fullest sense encompasses the physical, mental, social, economic, envi
ronmental, and spiritual well-being of people, is of concern to everyone and has the potential
to unite a broad base of people's movements. The potential has never been greater and the
need has never been more urgent.
The time to take united positive action is now!
on World H ealth
the PHA VIEW
THE STRUCTURE OF THIS PAPER
This draft paper aims to provide an overview of the current health situation, its major determi
nants and a number of suggested solutions. It also serves as an introduction to the five back
ground papers and we hope it will be a source of inspiration when you consider the People's
Charter for Health, and proposals for the Action Plan.
The analytical part of the paper begins with a discussion of the Current health situation in the
world and a definition of What ive may mean by 'health'. It is followed by a discussion of the
major Causes and determinants of the current health crisis. We have divided this into four
broad sections: the political economy, the social environment, the physical environment, and
the health sector. (These four areas are explored in more detail in separate background pa
pers.)
Following the analysis, there is a secHon on Strategies and actions for change. This analyses
and reflects on what is needed to challenge the current unfair and unhealthy situaHon. We
conclude by offering some Concrete examples and suggestions for action at different levels—
from local to global.
Health in the Era of Globalisation
THE CURRENT
tfFzlLTtt CRISIS
7|*n analysis of the health situation and its
Al determinants is a story of inequality and
S-unequal distribution. Although the last 50
years have witnessed improvements in life
expectancy, declining mortality rates (especially
infant mortality), and lower fertility rates in
most countries, these numbers tend to hide the
real disparities between and within countries,
between social classes and between men and
women.
In 1999, 20 million people died before reaching
the age of 50, while the mean world life expect
ancy was 66 years. Taking this relatively modest
age as a minimum of what should be morally
acceptable, we can conclude that 40% of all
deaths in that year could be considered prema
ture and preventable.1
While mortality rates in children under five
years old are less than 10 per 1 000 live births in
most countries in the North, most countries in
the South have rates of between 50 and 100, and
over 10 countries in Africa have figures of over
200. Furthermore, in a number of sub-Saharan
African countries infant mortality rates actually
started increasing in the 1980s due to economic
recession, structural adjustment, drought, wars,
civil unrest and HIV/AIDS. Since the beginning
of the epidemic there are more than 13 million
orphans due to AIDS2.
Even so-called developed countries have seen
worsening of health indicators among certain
sectors such as decreased life expectancy among
males in rural areas in Australia brought about
by long term unemployment caused by
globalisation and consequence of depression and
suicide. Other examples are found in the higher
morbidity and mortality rates of Afro-Ameri
cans in the United States.
In short, despite some gains, we have not made
substantive improvements in the main underly
ing determinants of health. Levels of poverty
remain unacceptably high, natural resources
have been drastically depleted and there has
been further degradation of the global environ
ment, in the longer-term threatening every
body's health. Although the world produces
more than enough food to feed its entire popula
tion adequately and medical technology has
made many advances, these benefits are un
evenly distributed. Wealth and knowledge are
increasingly concentrated in First World coun
tries and the gap between the have and the havenots continues to widen in all countries. This is
a central issue of human rights and social justice.
Each year, over 12 million children continue to
die from preventable diseases. An underlying
cause in more than half of these deaths is under
nutrition or hunger. TTiseases of poverty',
mostly infections and parasitic diseases, as well
as women's reproductive health problems, and
chronic diseases or 'diseases of modernity', are
on the increase. Cancer, hypertension, diabetes,
obesity, accidents and depression have become
serious world public health problems. Third
world countries are faced with the double
burden of disease where infectious and chronic
diseases are on the rise. This requires investment
and adjustment of the health services which are
impossible given the economic and political
constrains they face.
There has also been a resurgence of 'old dis
eases' such as tuberculosis, malaria, and vaccinepreventable diseases. This is as a direct result of
increasing poverty, deteriorating living condi
tions and inadequate health services. New
diseases such as HIV/A1DS have appeared and
are spreading most rapidly where social and
gender inequalities are the greatest. Increasing
crime and violence add to this growing health
crisis. The same is true for substance abuse,
increasing violence, suicide and other 'diseases
of despair.' Far from reaching the international
goal of 'Health for All by the Year 2000/ the
health of humankind is sadly compromised.
People's Health Assembly
new intemationalist/Dec 1997
OF COURSE TOU
WANT To BE HOMELESS AND MAINOUR ISHEP, 'MEAN WHO WOULD,
BUT YOU 5E£ (J£ MAP To STRUCTu/TALLY ADJUST YOUR COUNTRY OR YOU'D End UP
MISSINJ6 our oN ECONOMIC GROWTH,AND THEN You'D BE IN A RIGHT OLD PICKLE,
(/JOULDNT YOU, BECAUSE ONE DAY THAT ECONOMIC GROWTH l<y G0IN6T6 TRICKLE &OUJN
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Equality between the genders has been on the
political agenda of many countries and organisa
tions, and progress is apparent in some coun
tries. However, discrimination against women
continues to be a world-wide problem seriously
compromising their health. In some countries,
discrimination starts before birth and remains
part of women's lives until death. More than half
a million women die every year due to condi
tions related to motherhood. The overwhelming
majority of these preventable deaths occur in
the developing world, especially in Africa.
The increasing number of elderly in all societies
requires that conditions be created now for
healthy ageing. Attitudinal, physical and eco
nomic barriers to the inclusion of disabled
people have still to be removed to ensure their
full participation in each society.
AIDS is set to alter history in Africa—and the
world—to a degree not experienced by human
ity since the Black Death.
Poverty and the lack of general medical care
caused by rampant inflation and joblessness are
major contributors to the AIDS epidemic in
Africa - along with the social and cultural
particularities of that continent. In Zimbabwe for
example, nearly 40% of the women who present
themselves for HIV counselling and testing turn
out positive. Studies have also found that the
HIV infection rate among 15-20 year old girls is
five times that of boys of the same age. AIDS is
really a development and poverty issue and
should be treated as such.
Large numbers of people of all age groups are
finding it harder and harder to cope with such
characteristics of modem life as increased
unemployment, solitude, crime, domestic
violence, environmental degradation, mental
health problems, and the lack of physical, emo
tional and economic support systems.
Important disparities also exists in the provision
of health services. It is paradoxical but in the
world's poorest countries, most people, particu
larly the poor have to pay for health care from
their own pockets at the very time they are sick
and most in the need of it. The World Health
Report 2000 finds that "many countries are
falling far short of their potential, and most are
making inadequate efforts in terms of respon
siveness and fairness of financial contribution"3.
In the face of these alarming developments,
more and more people are finding the need to
organise themselves and find solutions to their
underlying problems.
A central thrust of the PHA process is to foster
and multiply such efforts through which people
acquire the power to make the necessary
changes.
What can you add to this overview of the
current health situation?
Do you have experiences and/or knowledge that
support or challenges these points?
What important aspects have, in your view,
been left out so far?
Health in the Era of Globalisation
WHAT DO
WE MEAN BY
DETERMINANTS
of
CRISIS
he paper is based on the objectives and
aspirations of the People's Health Assem
bly, which strives to ensure that all people,
regardless of age, gender, race, disability, nation
ality, social class, caste, place of residence, and
sexual or religious preferences, have the oppor
tunity to fulfil their potential.
The PHA is founded on the belief that
HEALTH?
T
We accept the World Health Organisation's
definition of health as a complete state of physi
cal, mental and social well-being and not merely
the absence of disease or infirmity. This holistic
health concept views health as a state of equilib
rium between human's external and internal
environment.
However, in the PHA we take the issue of health
further and see health and sustainable well-being
for ALL as the central objective of social devel
opment. We see health as a fundamental human
and social right to strive for.
To ensure health, peoples' basic needs for food,
water, sanitation, housing, health services,
education, employment and security must be
met. To enjoy more than just physical health,
people need self-esteem; they need a sense of
purpose, meaning and belonging. Healthy
societies require a balance between individual .
freedom and responsibility. Love, culture of
compassion, care and respect for life and spiritu
ality are as important to the well-being of indi
viduals, communities and nations as is the
economy.
Do you agree with this view on
what health consists of?
Do you have a different definition of health?
together we can build a better world, and that
organised grassroots action can bring about
positive social change. Action for change needs
to be grounded on a sound assessment—or
'situational analysis'—of the current reality.
Such a collective analysis needs to explore the
immediate, underlying and basic causes of ill
health and how these relate to the intercon
nected crises of our times.
This paper starts by looking at the problems that
face humanity and compromise its health. Some
pointers follow this to ways forward. It dis
cusses methods of awareness-raising, and
explores a range of possibilities for positive,
constructive action. It includes examples of
effective action people have already taken to
change their situation.
Causal factors affecting health
Different factors, acting at different levels,
determine the health of individuals, families,
communities and nations.
The most immediate factors that affect health
relate to starvation, lack of access to water,
inadequate food intake, exposure to infectious
diseases, intoxication from an unhealthy envi
ronment, smoking, inadequate treatment by
health services, accidents and violence. The
basic factors, in turn, relate to lack of food
security, lack of safe water, unsafe working
conditions and the way the health services are
organised in terms of their accessibility, ad
equacy and quality. The underlying causes are
those major cross-cutting issues such as the
shape of the economy, environment, agriculture,
employment, fairness of wages, human rights,
gender issues, and education.
These factors are interrelated and
reflect the economic and socio-politi
cal conditions of a country—and
increasingly, our globalised world. In
order truly to achieve health for all,
far-reaching transformation of society
at the underlying level is needed. Such
transformation must be directed
towards a more equitable distribution
of power and resources, participatory
democracy and good governance with
improved accountability and trans
parency.
1 CD
People’s Health Assembly
new internationalist, august 1996
Health cuts across all aspects of society. Any
division into clusters or thematic areas is there
fore arbitrary. For purposes of our analysis we
have chosen to present them in the following
four areas:
1. The political economy
2. The social environment
3. The physical and natural environment
4. The health sector
1.
The Political Economy of health
The most significant determinants of health in
the world today are economic and political
factors that have colonial roots. Who has control
over resources and decision-making, and who
has the power over whom, determines the way
countries and the world are organised and
ruled. This impacts on the health status of
people and the way health services are organ
ised. Most of the underlying and basic causes of
ill health can be found here and the solutions
being offered benefit much more the planners,
loan givers -usually international financial
institutions and the associated govemmentsthan the recipients. Their needs are usually not
met and end up loaded with heavy debt servic
ing, which results in further expenditure cuts in
essential social services. From a health point of
view, the current trend towards economic
globalisation, the lack of equity and distributive
justice aggravates the growing health crisis and
widens the growing inequality gap.
Statistics show the existence of overwhelming
inequalities in the world today:
88 Total GNP per capita (global production per
person) has more than doubled in the last 50
years. More than enough food and goods
are produced to meet all people's basic
needs. Yet one in every four children is
malnourished.
88
88
At the end of the 1990s, a fifth of the world
population living in 'rich' countries com
manded 86% of the world's GNP while the
poorer fifth commanded only 1%.4 As a
result, poor people are denied access to basic
resources like food, clean water, shelter, a
safe and clean environment, and are increas
ingly exposed to violence.
Wealth and power have become more and
more concentrated in the hands of a small
powerful minority. A handful of
transnational corporations (TNCs) currently
control 33% of the world's productive assets,
while they employ only 5% of the global
workforce5. Annual turnover of many TNCs
exceeds the annual budgets of several large
developing countries.
88 Today the 450 richest persons in the world
have an annual income greater than that of
the poorer half of humanity. While the chief
executive officers of giant corporations have
incomes in the millions of dollars, one fourth
of the world's people struggle to survive on
less than USD 1 dollar per day. Many have
to do so by selling their last resource,
namely themselves, that is their blood,
organs and engage in sexual slavery.
88
Financial institutions such as the World Bank
and the International Monetary Fund have
been major influences in determining the
current model of development. They have
universally prescribed structural adjustment
programmes (SAPs), which have cut employ
ment and investment in the social sectors,
and removed protection to local industries,
barriers to outflow of funds and labour
regulations. These programmes have had
important consequences for the level of
investment and development of the health
services as well as for the major determi
nants of health.
It is not absolute shortage but rather the increas
ingly unfair distribution of resources that leads
to the current unacceptable levels of hunger,
poor health and impoverishment. It is the
globalisation of the inequitable and unsustain
able market economy that underlies the over
whelming health, environmental and socio
political crises of our times.
Health in the Era of Globalisation
I A
a. Globalisation - some features
Not only has the gap between the rich
and the poor widened dramatically in
recent decades, but globalisation has
aggravated the hardships of the disad
vantaged millions. A host of laws,
policies, and trade agreements have been
introduced, which advance the planetary
reach of TNCs and speculative investors.
At the same time the rights and selfdetermination of the poor and relatively
powerless peoples and nations are
undermined.
What are some of the impacts of the current thrust
of globalised economy?
3® It has increased poverty, which is the single
most important underlying factor causing ill
health.
3® It has increased the disparities between the
rich and poor, further fuelling poverty and
disrupting the social fabric of individual
nations.
8® It is driven by short-sighted, growth-centred
economic policies, which lead to
overexploitation and destruction of the
environment. This affects the health of
people and threatens the medium- to long
term life-support systems of our earth.
3® It is directed by corporate interests with profit
maximisation as the primary objective.
3® States are reluctant and unable to take respon
sibility for the common good. Greater debt
burdens have not facilitated the economic
situation many states find themselves in.
3® Global competition drives companies to cut
costs and places further pressure on indi
vidual countries to 'sell out' their environ
ment and labour standards.
3® Growing unemployment and underemploy
ment leads to further social problems and ill
health.
3® Weakened tax bases, forced decreases in
import tariffs and lifting of quantitative
restrictions obstruct countries' ability to
provide basic social services. Severe cut
backs in the social and health sectors have a
direct effect on the health status of people.
3® This globalised 'casino economy' is increas
ingly removed from any connection with
place and reality, and is characterised by
enormous financial flows and speculation.
Profit maximisation for shareholders is a
driving force. Ironically, a significant pro
portion of the shareholders is made up of
ordinary workers in the North, who through
the speculation of their pension funds,
People's Health Assembly
accelerate the trend towards cost-cutting—
thereby risking their own jobs and social
security.
Further features of the globalised economic order
can be identified:
3® The emphasis on free trade has increased the
'unfair trade' between developed and devel
oping countries. This has seen the devalua
tion of Third World currencies— supposedly
implemented to increase developing coun
tries' export trade, but instead having the
effect of depressing the wages and standard
of living of vast segments of the population
around the world.
3® There is an increase in the rate of unemploy
ment—seen even in developed countries.
Increasing numbers of people, especially the
young, are unable to find jobs in the formal
sector—which traditionally provided secu
rity and a sense of stability. As a conse
quence, large numbers of people, including
100 million children, are forced to seek
employment in the informal sector.
3® An increase in the external debt of Third
World countries has meant that a significant
share of their income is used to pay back
their debt with often crippling interest rates.
This has resulted in an increased flow of
resources from the Third to the first World.
3® The implementation of economic reform
programmes such as SAPs has destroyed the
domestic economy, limited governments'
positive participation in their economies by
reducing their employment capacity as well
as public spending in critical social services
such as education and health.
3® Human and environmental costs are second
ary in the thrust to privatise virtually all
sectors of production and public services.
More value is placed on private profits for
the fortunate few than on public goods for
everyone.
It has increased the unit cost of development
in poorer countries thereby increasing
corruption and dependency.
;<a For the marginalised population, all these
increased hardships have led to widespread
deterioration in physical, mental, social and
environmental health.
s>;
As 'big industry' increasingly shapes the world,
policies that protect human well-being are
systematically eroded. The production of harm
ful technology, goods and products, in it a crime
against humanity has proliferated out of control.
The world's three" largest industries—weapons,
illicit and addictive drugs, and oil—all promote
their products in ways that contribute to physi
cal and structural violence. These industries take
an enormous toll on human and environmental
health. The tobacco, alcohol and pesticides
industries, among others, have powerful politi
cal lobbies, ensuring that weak governments
subsidise rather than seriously regulate or
restrain them.
The military industry is very large and profitable
and depends on conflicts and violence, which
are so prevalent. In 1999 it was worth USD 745
billion dollars, USD 125 dollars per capita. The
poorer regions spend the highest percentage of
their GNP on the military, many times their
health or education expenditures.6
On the other hand, new international organisa
tions such as the WTO are increasing their
influence, through various agreements, and
having an adverse impact on health, food secu
rity and the environment. The Trade-Related
Intellectual Property Rights (TRIPs) regime that,
among other things, allows patenting of seeds
will pose a threat to genetic resources, sustain
able agriculture, food security and the well
being of farmers. Increasing patent protection
will lead to increasing prices and reduced access
to medicines, which will continue to be under
monopoly control.
2.
The social environment
As a result of these economic and political factors,
there is an increasing erosion of the social fabric of
societies, institutions, communities and families.
a. Weakening of institutions
One important trend resulting from the current
global socio-economic development model is the
weakening of national public institutions with
forced rapid privatisation of services and disin
vestment of public sector institutions, which is
increasing unemployment, creating social and
financial insecurity and decreasing government
control and accountability. At a time when
governments need to increase their capacity to
create and enforce mechanisms that will ensure
equity and participation, governments around
the world are in fact losing their capacity to fulfil
their basic responsibilities of ensuring security
and promoting equity. Increasingly govern
ments' roles and responsibilities are being
transferred to the private sector, corporations
and other national and international institutions,
which are not transparent or accountable to
anyone.
Other traditional institutions, such as political
parties and trade unions, are under increasing
stress. People no longer feel that political parties
represent their interests, and they are disillu
sioned with the electoral processes—this is at a
time when there is an increasing need and
demand around the world for greater democ
racy and participation.
Trade unions are under threat of losing their
constituencies and the confidence of workers.
This is mainly as a result of the current trend
towards individual, productivity-oriented
labour relations, which do not foster workers'
organisations and in many instances represses
them. At the same time there is a new trend
where workers' organisations in different coun
tries are organising and addressing issues
TNCs are promoting and dumping harmful
products, processes and technologies such as
tobacco, asbestos, pesticides, dioxin, genetically
manipulated foods and genetically engineered
seeds without adequate biosafety trials and
dumping of toxic waste. In particular, they are
releasing toxic, chemical and nuclear materials
in Third World countries where they benefit
from weak governments and weak prohibitive
legislation.
What is the impact of globalisation
in your community?
Health in the Era of Globalisation
1^—5
related to international agreements, taking a
labour perspective, supporting each other and
challenging the unjust corporate decisions.
There is increasing use of money and disinvest
ment of public sector institutions, which is
increasing unemployment, creating social and
financial insecurity and decreasing government
control and accountability. Corruption is en
demic in all kinds of institutions, playing a
further role in weakening their legitimacy.
b. Employment and Unemployment
Expansion of trade does not always mean more
employment and better wages. In the OECD
countries, employment creation has lagged
behind GDP growth and the expansion of trade
and investment. Globally more than 35 million
people are unemployed, and another 10 million
are not taken into account in the statistics be
cause they have given up looking for a job.
Among youth, one in five is unemployed.
In both poor and rich countries, the neoliberal
model, with its economic and corporate restruc
turing and dismantling of social protection, have
meant heavy job losses and worsening employ
ment conditions. Jobs and incomes have become
more precarious. The pressures of global compe
tition have led countries and employers to adopt
more flexible labour policies and work arrange
ments with no long-term commitment between
employer and employee.
c. The role of corporate media
The promotion through corporate media of
unethical advertisement and unhealthy lifestyles
have displaced indigenous, natural nutrition and
cultural practices (e.g. bottle-feeding versus
breast-feeding, fast foods replacing nutritious
and cheaper local foods). In addition media is
also promoting tobacco, alcohol and drugs.
Through unethical and aggressive promotion
corporate media is presenting women as sex
objects, which has a negative effect on their selfesteem and image, is degrading, worsening
discrimination and increasing violence.
d. Conflict, violence and war
War and conflict over control of resources are
present in every region of the world (e.g. Sierra
Leone over diamonds, Iraq over oil). Intolerance
and increasing conflicts over ethnicity and
religion have divided communities and created
war and destruction, especially hurting and
maiming women and children. The dislocation
of populations due to migration for economic,
People's Health Assembly
political, and ethnic
conflicts has a
direct influence on
the health and
well-being of
millions of people and
an important number of
people are disabled as a
result of land mines
explosions.
Violence in all its
forms is present in
every society. We are
witnessing an increase
in domestic vio
lence, human
trafficking, children
soldiers and drugrelated violence.
The sex industry has expanded as women and
children are pushed into prostitution to try to
ensure the survival of their families and depend
ants. Sexually transmitted diseases and AIDS are
most common where there is the most exploita
tive gap between men and women.
e. The family
Adverse socio-economic conditions have altered
traditional family structures all over the world.
There is an increase in the number of divorces
and single parent families, without the required
social and economic structures to support them.
This is especially taxing on women who find
themselves under greater stress as they are left
with the responsibility of caring for the home,
and trying to eke out a living.
f. Education
Education inequalities—in access, attendance,
quality of teaching and learning outcomes—
perpetuate income and social inequalities in
developing countries across the world. Poor
children attend poor schools and have less
opportunity to complete their basic education or
go on to secondary and higher education.
Misallocation of resources, inefficiencies or lack
of accountability are prominent attributes of the
organisational structure of education in develop
ing countries, contributing to the poor state of
education.
Is the situation described above
relevant in your setting?
Are there other important social factors
in your community and country?
What are people and governments doing
to address them?
3.
The physical environment
Although the destruction of the environment is
not new to the present era, it is reaching unprec
edented levels. Fuelled by a runaway global
economic system, the resulting environmental
deterioration threatens to harm the planet's
ecosystems irreversibly. If not urgently coun
tered, global environmental changes will endan
ger our entire social and economic systems, with
disastrous effects on the health and even sur
vival of our own and many other species.
a. Environmental threats to health
Environmental threats to people's health are
both direct and indirect.
Direct threats include exposure to toxic sub
stances, contaminated water, polluted air,
radioactivity and environment-induced natural
disasters. New technologies such as genetically
modified foods and nano-technology can com
promise health and upset ecosystems.
Indirect threats include environmental degrada
tion, for example, food shortages due to the
changing climate that damage both farmland
and forests. There is an increase in health prob
lems among 'environmental refugees' in situa
tions where people are forced off their home
lands because of the destruction of local environ
ments; and people are being killed or maimed in
wars fought over scarce natural resources.
Environmental problems may have immediate
or delayed effects on health.
Immediate effects are easier to recognise. For
example, people get sick from drinking chemi
cally and biologically polluted water or breath
ing air polluted by poisonous chemicals, or
starves because farmlands have been destroyed
with crop failure, pests and climate changes.
demies. In the future whole regions may lose their
capacity to grow food.
Disputes over resources have already lead to re
gional wars (for example, oil in Iraq, Nigeria and
Somalia, forest in the Amazon and Sawara, Dia
monds in Sierra Leone). In the near future, owner
ship of biological wealth through unjust interna
tional regimes of TRIPS can also lead to conflict.
b. A crisis ofjustice
The environmental crisis is a crisis both of nature
and of justice. Although the growing population
of the Third World is often blamed for the
destruction of the environment, the industrial
societies in the North and the elites of the South
are in fact the major culprits. On average, a
person in the United States consumes about 50100 times as much energy, water and non
renewable resources, and leaves behind 50-100
times as much garbage and pollutants, as does a
person in Bangladesh. Yet the Bangladeshis will
suffer much more from environmental imbal
ances.
Millions of people's health will be at risk as the
climate changes and global warming causes sea
levels to rise, largely a consequence of affluent
lifestyles in the North. In both the North and the
South, the poor and marginalized will suffer the
most. They have the most environmentally
hazardous jobs, live closest to waste dumps and
polluting industries, and are the first to become
environmental refugees as their livelihoods are
destroyed.
The need for GNP growth and industrial devel
opment in the South is undisputed. However
these processes need to be based on environmen
tal regeneration rather than continued environ
mental degradation, to ensure the sustainability
of the planet and the well-being of the
populations in the South.
circular on habitat, may 1996
Delayed effects are often more difficult to link to
their causes. For example, there is an increase in
the incidence of cancer believed to be caused
from exposure to pesticides, carcinogenic chemi
cal substances, or low levels of radiation used in
industry and food-processing. These threats
have an erosive effect on the health of the people
of our planet.
Changes in the environment pose some of the most
alarming threats to human health. Changes in the
world's climate caused by global warming are a
threat especially to islands and coastal areas, where
increased incidence of droughts and floods could
kill millions of people and cause new health epi-
Health in the Era of Globalisation
t
4.
The health sector
Health sendees today are inaccessible,
unaffordable, inequitably distributed and
inappropriate in their emphasis and approach.
Throughout history societies have responded to
illness and disease by organising their health
services, with different approaches, practices
and staffing. In most countries traditional and
Western medical systems have coexisted and
people have used them either for different
purposes, or in an arrangement that suits their
needs and resources. People make the initial
decision of what system to use depending on
their culture, perceptions and assessment of
either system's capacity to solve their problems,
as on the accessibility of both systems.
c. Underlying causes
Our current environment and health crisis is
associated with the following:
3® The misleading view of progress and devel
opment as a universal, linear pattern of
societal change where different societies all
take part in the same race towards industri
alisation and ever-increasing wealth;
3® The notion of nature as an inert, mechanical
construction, existing only to be extracted
and exploited for human short-term benefit;
3® The failure of economics to base its theories in
an environmental context and to recognise
ecological constraints;
3® The unsubstantiated belief that neoliberalism,
corporate concentration and unchecked
international trade policies will lead to 'trickle
down,' fairer consumption patterns and the
eradication of poverty.
In your opinion, what are the
environmental threats
to your community?
What is producing them?
Is this an issue for you or your organisations?
Is something being done?
The particular organisation of a system depends
on the mix of human, financial and material
resources. In most countries the Western medi
cal model is applied in the public and private
sectors. The extent and level of care provided by
different countries range from universal public
services (Cuba), universal health insurance (most
countries in Europe, Canada and Australia), to a
variety of social security' schemes (Mexico) or of
private schemes (United States).
There are innumerable examples of peoples'
struggles for health over the last century, with
different countries and communities evolving
their own systems to manage illness and health.
Community-based Primary Health Care (PHC)
programmes developed by communities and
trained community health workers (CHWs) have
been very important in the improvement of the
health conditions of many rural communities
around the world.
The effectiveness of these experiences were
recognised and became the basis of the 1978
Alma Ata Declaration, where comprehensive
PHC was accepted and endorsed by all the
WHO and UNICEF member states. The prime
basis was the acknowledgement that we need to
act upon the underlying determinants of health,
including those political and economic factors
that determine the health status of people and
populations.
The economic policies of the 1980s led to the
implementation of structural adjustment pro
grammes (SAPs), which increased the pressure
on governments to decrease their participation
and commitment to universal health services,
limited the implementation of comprehensive
PHC and promoted a wave of health care 're
forms'.
1©
People's Health Assembly
The widespread efforts and experiences of PHC
projects in the 1970s and early 1980s were
boycotted or ignored, and the projects them
selves were under pressure to abandon their
comprehensive approach in favour of more
'practical and feasible' strategies, i.e. selective
primary health, child survival, other limited
targets and now vertical programmes pushing
limited agendas.
Severe cuts in national budgets for health re
sulted in the deterioration and often the collapse
of services at many levels. These conservative
fiscal policies, with inadequate resource alloca
tions for capital and recurrent costs, resulted in
deteriorating health facilities, shortages of
equipment, drugs and transportation, reduction
in the numbers of health personnel, and deterio
ration in their performance as a result of worsen
ing working conditions.
The funding cuts brought about by certain
components of Health Sector Reform, notably
decentralisation and privatisation of services,
concentrated health services in urban and
affluent areas. While decentralisation of health
care management has been promoted as a
mechanism to improve the efficiency and ac
countability of health services, it has, in effect,
frequently become a mechanism for further
withdrawal on the part of central government
from their financial responsibilities.
Health Sector Reform has promoted privatisa
tion through such mechanisms as public-private
partnerships and other approaches to health
financing. These initiatives, together with the
lack of human and other resources in the under
funded public sector, have led to the rapid
growth of self-medication and a growth of the
private health sector. Large numbers of poor
people have been left with little or no access to
any health care.
In this context however, many communities have
strengthened or developed their programmes and
there are examples of CHWs working in non
governmental community health programmes
which are addressing people's needs.
What is your experience of
privatisation of health services?
a. Health care as a commodity
Health care has been converted from a basic right
into a product that can be sold or exchanged for
profit, resulting in an emphasis on the curative
aspects of health at the expense of the preventive
and promotive dimensions of health care.
The dominance of curative care has been rein
forced by the commercialised and
pharmaceuticalised health care industry, the
medicalised education of health professionals
and a renewed emphasis on "cost-effective"
health interventions.
The past decades have witnessed an increase in
the influence of the health care industry that
produces, for example, pharmaceuticals, medical
equipment and baby food. Funding for research
on 'diseases of poverty' is minimal compared to
that allocated for the study of 'diseases of
affluence' in the industrialised world.
The medical equipment industry has mush
roomed. Although this has facilitated the diag
nosis and treatment of some conditions, it has
driven up medical costs, has further inflated the
'magic bullet' myth of curative care and ren
dered services less affordable to the poor—or
put them out of their reach altogether.
Health professionals' education remains domi
nated by a biomedical approach (treatment of
illness rather than promotion of health). With few
Health in the Era of Globalisation
exceptions, training programmes have failed to
integrate the principles of public health and PHC
into their core curricula. PHC has at most been a
small component of a marginalized public health
course, rather than informing the whole curricu
lum.
b. Problems in the implementation of PHC
The institutional mechanisms needed to imple
ment comprehensive PHC have been relatively
neglected. Insufficient thought, resources and
energy have been allocated to important aspects
of PHC, such as the development of intersectoral
action and community involvement. Little effort
has been made to incorporate the lessons learned
from the innovative experiences of a multitude of
community-based health projects. The dominant
technical approach is medically driven, vertical
and top-down and reflects in the organisational
structuring of many ministries of health and the
WHO itself.
Many PHC projects today focus on medical and
technical interventions, such as the child survival
initiative, which mainly promotes two 'techno
logical fixes'—immunisation and oral rehydra
tion therapy.
This trend has been reinforced recently by new
methodologies designed to promote cost-effec
tiveness in health. The development of DALYs
(disability-adjusted life years) as an index to
quantify the burden of disease, and to cost the
effectiveness of certain interventions, has re
sulted in the shift of focus towards selected
medical technologies at the expense of broader
social interventions. The DALYs approach,
promoted by the WB, and uncritically embraced
by WHO, has also in effect devalued important
aspects of health care, such as caring, which
cannot be easily measured for cost-effectiveness.
1<5>
People’s Health Assembly
Health care as an instrument of social
control
Health care is increasingly used as a subtle and
widespread instrument of social control. Central
to this is the ideology of medicine, which mysti
fies the real causes of illness, often attributing
disease to faulty individual behaviour or natural
misfortune, rather than to social injustice, eco
nomic inequality and oppressive political sys
tems. This is particularly apparent in situations
of war and political oppression.
c.
Examples of such victimising and conservative
approaches to health care include the heavyhanded promotion of family planning, in isola
tion from social development, as a means of
population control. Further oppressive forms of
health education, which tend to blame ill health
on people's 'lifestyles' while neglecting the social
determinants of their 'bad habits' and patterns of
consumption, are dominant.
We would like to know how accessible
health services are in your community and
if you think there are problems in the way
they are organised and managed.
Are the services comprehensive?
Does your community feel
they address your needs?
What is the role of health workers?
What are their work conditions like?
THE WAY FORWARD
challenging the current
|NEQU|TABl-E
anj
UNHEALTHY
GLOBAL MODEL OF
DEVELOPMENT
1. Movements for change
he dimensions and complexity of the major
problems affecting human and environmen
tai well-being today are hugely different
from the situation that confronted past genera
tions, and far more difficult to challenge. There
was a time when people in one part of the world
could come together and take a stand against
unfairness or injustice at the local or even na
tional level and succeed. Today, the forces that
threaten human and environmental well-being
are increasingly global, powerful, sophisticated
and well coordinated.
T
New strategies are needed in the struggles for
social change, to match the size and character of
the forces that we are dealing with.
Actions for positive change need to be taken at
the local, national and/or international level.
Individuals, groups of concerned people, pro
gressive organisations, or networks of national
or international coalitions can take them. In
today's world, where obstacles to personal and
community well-being are rooted in global
policies and decisions, actions to resolve injus
tices at the local level should lead people to join
in more far-reaching global action for change.
In the struggle for a common cause, there is a
need to bring together:
88
88
a wide range of diverse sectors and move
ments;
activists from all nations;
88 concerned people of different races, classes,
castes, sexual preferences, ages and profes
sions;
88 people and groups whose work for change is
focused at different social levels: individual,
family, national and global;
to) NGOs, labour unions, women's and human
rights groups, watchdog groups, environ
mentalists, health promoters, community
health workers, progressive political parties,
social activists in diverse fields, eco-economists, peace/anti-war and anti-nuclear
groups, groups working for universal health
coverage.
As the worldwide crisis deepens and more and
more people from all positions on the social
spectrum begin to realise that the current global
economic system has lethal flaws, the
groundswell for change is gaining momentum.
There is an urgent need for a new, alternative
vision of development—one that promotes
human and environmental well-being.
Such a vision is taking shape among many
people's organisations around the world. De
spite their diversity, certain common threads
stand out. These include:
88 an attempt to increase public participation to
counter the concentration of economic,
political and corporate power;
88 an effort to establish healthy communities;
88 reshaping the global economic order to
ensure environmental sustainability, equity
and social justice;
88 the call for a closer and more spiritual
relationship with nature and communities;
and
88 a commitment to collective solutions that
maintain considerable individual freedom.
The quest for sustainable societies calls for
drastic changes in the current world order. It
requires the formation of strong broad-based
Health in the Era of Globalisation
people's movements. All movements (health,
environment, social, women, among others)
must join forces and be seen as part of the same,
overall movement for social change, social and
gender justice.
We need to focus on a wide range of issues
including corporate responsibility, election
financing reforms, social and gender justice,
foreign debt cancellation, corporate accountabil
ity, participatory democracy, disability and
elderly rights, progressive education,
biodiversity and community health care.
2. Types of Action for Change
What types of action are available and have been
used successfully by individuals and movements
working for change? The possibilities are numer
ous and have proven to be effective time and
time again.
3® Actions to counter misinformation and
raise awareness;
3® activities that help empower people to
assess their needs without mystified pre
scriptions and to take action themselves;
8® activities to promote better coping strate
gies, provide services and develop local
alternative solutions to immediate prob
lems;
3® actions that drastically improve networking
and information-sharing;
3® actions that promote solidarity between and
among people's organisations;
3® exerting and multiplying political pressure
to counter policies and decision-making that
only benefit the few;
3® pressure governments to involve propeople organisations in policy decisions;
3® actions to claim rights and force those in
power to listen;
3® promote self-governance by the people;
3® acts of civil resistance;
38 economic pressure through our roles as
consumers, taxpayers and holders of invest
ment funds;
3® advocate participation in social and political
events at all levels, from the villages, re
gions, nations and internationally;
The way forward is not only paved by grand
designs. There are many ways to contribute to a
healthier world. All meaningful gestures and
small personal acts of kindness and solidarity
People's Health Assembly
also matter. Because this is not enough, we have
to work together to plan action that goes from
the local to the global level. That is our challenge
for this decade and beyond!
Building on people's positive traditions is an
important way forward. By way of example, in
the Punjab of India, even in the poorest commu
nities there are almost no street children. Fami
lies traditionally welcome children into their
homes, including those who are orphaned or
abandoned. Through their tradition of helping
one another in hard times, people living in
extreme poverty find ways of coping. But coping
is palliative; overcoming and resolving the
causes is the challenge.
Action for positive change can be approached in
many different ways, most often beginning with
a particular focus of concern, such as on environ
mental issue, changes in health policies,
globalisation, economic equity, fair trade, wom
en's rights, debt cancellation, or food security. It
is important, to coordinate activities and work
together with organisations, movements, NGOs
and community groups that have a track record
of being 'community-supportive' at the local,
regional or national level.
What follows is a selection of different ap
proaches of taking action for change. With each
approach, an example of programmes, networks,
or coalitions working in this field are given.
a. Awareness-raising and empowerment
Misinformation has become the modern means
of social control. People—regardless of educa
tional level—often have little knowledge of the
injustices done to disadvantaged people. The
media has a way of keeping us strategically
misinformed.
Only when enough citizens become fully aware
of the issues will it be possible to place the
common good before the interests of powerful
minorities. Creating such public awareness is an
uphill struggle. More empowering forms of
education and information-sharing are needed.
Currently, schools tend to teach history in ways
that glorify those in power, and follow teaching
methods that instil conformity and compliance.
To counter this misinformation and to mobilise
people for a more equitable society, we need
alternative methods of education and informa
tion-sharing that are honest, participatory,
empowering and that can bring people together
as equals who can critically analyse their reality
and take united action.
Activities that empower people to take
action
Community-based health programmes and
community initiatives in health care planning
and development in various countries have
brought people together to take back control
over their health and raise awareness of the
underlying causes affecting their health. These
programmes start with a community diagnosis
where it becomes clear to people that inequality
and the power structures that perpetuate them
are the root cause of ill health.
b.
Project Piaxtla in Mexico has developed different
educational methods for information sharing.
Since the mid-1960s, the village health promoters
working in this rural area have developed
interactive teaching methods to help people
identify their health needs and work together to
overcome their problems. As a result, resource
books such as Where there is no doctor, Helping
health workers learn and Nothing about us
without us (by David Werner) are now used as
educational tools worldwide.
A community diagnosis/situational analysis is
one way of starting a group learning process —
participants are able to identify and prioritise
health-related problems and other shared con
cerns.7
Another method developed by this project and
later shared with other organisations in Central
America and Asia is the Child to Child pro
gramme which works with school-age children
learning ways to protect the health of other
children. Children learning through experience do
that. Children conduct their own surveys and
discover answers for themselves; they learn to
work together to help each other.
Gonoshasthaya Kendra (GK) is a community
health and development programme in Bangla
desh, which began during the war for national
independence. Village women have become
community health workers and agents of change.
Villagers collectively analyse their needs and build
on the knowledge and skills they already have.
Further, we have to build on global solidarity
and find ways to communicate truthfully and
directly. Alternative media, including the
Internet, for those with access to it, provide
avenues to be exploited. Storytelling, street
theatre, awareness-raising comics and novellas,
as well as community radio and TV, and the
alternative press, offer vital complementary
outlets that we need to use more efficiently.
Using this approach GK has expanded in many
areas. It has different training courses that enable
women (in particular) to get non-traditional jobs.
GK is currently working in 13 Districts and 21
sub-districts where it covers a population of over
600,000.
A few examples of alternative periodicals that
provide examples of watchdog initiatives and
grassroots action for change include:
Multinational Monitor
YES, A Journal of Positive Futures
Third World Resurgence
Resurgence
The New Internationalist
The Nation
Dollars and Sense
The Progressive
Health for Millions
Z Magazine
Mother Jones
HAl Bulletin
Medico Friends Circle Bulletin
Journal of Medical ethics
Beeja
Health Action
The Centre for Information and Advise in
health (CISAS) Nicaragua provides popular
education and communicarion services since 1983.
Health work is seen as an instrument for commu
nities to develop and organise, think and trans
form their reality through collective action. It has
different offices and documentation centres
throughout Nicaragua and is active in the coordi
nation of regional primary health care networks.
All its work has a gender perspective.
Are you aware of any successful examples of
similar community-based initiatives?
Do you know of any story or case study that
would illustrate or add to some of these points?
Can you help us enrich this resource by
sharing your own experiences?
Telemanita is an NGO
working in Mexico, that
has been training
women to use video
technology to make their
own documentaries,
promotion and training
materials.
’
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Health in the Era of Globalisation
c. Networking and information-sharing
Effective international South-North advocacy
networks on health and equity issues are being
formed. These link together existing and newly
established networks active in Public Health,
bridging continents and connecting grassroots
movements with people working on lobbying
and advocacy.
By joining forces we are able to consolidate a
stronger base to confront injustice and inequity.
Strength in numbers not only gives us protection
but also makes us a force to be reckoned with.
Networking allows for cross-fertilisation of
experiences, methods and ideas. People need to
know what efforts are being made elsewhere to
oppose global forces and improve communities'
conditions.
Electronic networking for change needs, wher
ever possible, to be exploited more decisively as
a useful avenue for dialogue between grassroots
groups engaged in popular struggles. Currently,
however, computers and the Internet are avail
able to only 1% of the world population.
Hundreds of progressive, social-action and environ
mental action 'e-groups' exist. For example:
•
Equinet is a mostly African discussion group
of activists working for fairer, more equitable
distribution of health and other resources.
•
E-drugs is a group that shares information
about essential drugs, relating to policy, prod
uct safety, quality and rational use of drugs.
• There are different e-groups dealing with HIV /
AIDS both from the medical and the human
rights perspective.
Health Action International (HAD lobbies
governments and international bodies (such as
WHO) to formulate codes, pass resolutions and
develop policies to ensure that people who need
them have access to safe, appropriate and afford
able medicines and these are used rationally. It
monitors the unethical behaviour of industry and
the selling and promotional practices of drug
companies. It challenges international regimes of
TRIPS and WTO.
d. Political pressure and resistance
Watchdog groups and organisations working
for corporate accountability and social justice
have an important role to play. A watchdog
group is a collective of people who monitor the
activities of corporations, government agencies
or international institutions, and 'blow the
whistle' (and encourage public protest) when
these entities violate human rights or endanger
human or environmental well-being.
The International People's Health Council
Watchdog groups are proving influential in
curbing the abuses of big business, especially in
the absence of needed government regulations.
Often, their most important weapon is to raise
public awareness and outrage, motivating
people to take action. Where the mass media is
unsympathetic to the issues raised, we need to
utilise the alternative press, radio and commu
nity TV.
(IPHC) is a coalition of grassroots health pro
grammes, movements and networks. It is commit
ted to working for the health and rights of disad
vantaged people. It strives towards a model of
people-centred development, which is participa
tory, sustainable and makes sure that all people's
basic needs are met.
Self-employed Women's Association (SEWA) in
India is a Trade Union of women in the informal
sector based on Gandhian ideology. It has linked
workers rights with health and economic rights. It
supports different services: training programmes,
health services, loans, income generation pro
grammes and finds markets for women crafts.
People's Health Assembly
Bank Watch monitors and reports on the policies
and projects of the international financial organi
sations, especially the World Bank.
The '50 Years is Enough' alliance has involved
over 200 organisations around the world and
demanded that the World Bank stop its policies
and programmes that favour the interests of big
business at the expense of human and environ
mental well-being. In the United States, 50 Years is
Enough lobbied the government to restrict fund
ing of the World Bank and International Monetary
Fund until they improved disclosure, environ
ment, and workers' rights policies.
The International Forum on Globalisation, with
citizen representation in both the First and Third
World, is one of the leading collectives of activists
attempting to raise public awareness on the health
and environment-damaging aspects of the global
economy, as well as pushing for corporate ac
countability. It has successfully campaigned with
others against MAI and contributed to it being
squashed.
The International Breast Feeding Action Net
work (IBFAN) is involved in health education
about the importance of breast-feeding; at the
international level, it campaigns to stop the
unscrupulous promotion of bottle-feeding by
transnational corporations. IBFAN spearheaded
the world-wide boycott of the Nestle corporation
and stood behind the International Code on breast
milk substitutes introduced by UNICEF, WHO
and the United Nations and endorsed by virtually
every nation except the United States. At the
national level, to give the code legislative support,
the government of Papua New Guinea passed a
law prohibiting the sale of baby bottles and infant
formula except by prescription. What started out
as organised action by a group of concerned
women has gone a long way toward raising public
consciousness and opposing the profit-beforepeople behaviour of giant transnationals.
Advocacy and lobbying can play a particularly
important role in the struggle to improve poli
cies both at the national and international levels.
In this area, efforts are made from the local to
the international level.
An example is the campaign of the Multinational
Resource Centre and the Physicians for Social
Responsibility against the burning of hospital
waste, an industry that contributes to poisoning
the global atmosphere with dioxins, mercury, and
other deadly and cancer-causing poisons. They are
protesting against the World Bank for promoting
the use of these medical waste burners in health
sector projects in at least 20 countries. A Senega
lese anti-incinerator network says of the World
Bank's health sector projects in Africa, 'We want
funds to treat us and not to poison us'.
The Zapatista uprising in Chiapas, Mexico, was
launched by a handful of impoverished tribal
people on 1 January, 1994, the day that the North
American Free Trade Agreement (NAFTA) came
into effect. The Zapatistas did not want to over
throw the Mexican government, but to make it
respond to the people's most basic needs for land,
food and health care. At first, the Mexican
government tried to crush the 'mini-revolution' by
brutal military might. But through their wellplanned communications network (including the
Internet) the Zapatistas sent an SOS to people's
organisations, progressive NGOs and news
reporters around the world. To a large extent it
was the international outcry that forced the
Mexican government to hold back its assault and
enter into negotiations with the Zapatistas. While
the results so far have been far less than hoped for,
at least some of the laws protecting the rights of
small farmers were partially reinstated. The
struggle continues to this day and international
support continues to be vital to its success.
Health in the Era of Globalisation
Advocacy effors in the area of trade and invest
ment are increasing in order to oppose threats to
equity-oriented health policies and systems, such
as the current developments in the areas of
services and government procurement under the
WTO and the plans to establish a multilateral
investment agreement. Advocacy can be focused
on specific local issues or can take the form of
large international campaigns.
During the UN Social Summit in Denmark,
progressive NGOs from around the world held a
parallel Summit nearby, gave lectures and led
demonstrations to counter the economic
globalisation promoted bv corporate interests
and the World Bank. An ‘Alternative Copenha
gen Declaration' was drafted and endorsed by
hundreds of NGOs.
An example is the Jubilee 2000 campaign to solve
the problem of Third World debts. Jubilee 2000 is a
coalition of religious and secular groups from all
around the world working on this issue.
There are many examples of acts of resistance,
when people organise and take a stand for the
common good that can lead to public outrage
and sometimes to an eventual retracting by the
authorities.
Another example is the proposed tax on interna
tional financial transactions: the Tobin tax. The
proposal is to use the proceeds from such a tax to
meet basic human needs. While such a lax would
do little to transform our unjust and ultimately
unsustainable free market economy, it could at
least provide huge proceeds to help redress the
damage.
One of the most effective means of gaining
public attention and support for an alternative
position are organised mass demonstrations,
protests and 'alternative assemblies' around
key international events. This is especially
appropriate when the event is staged at the same
time and in the same place as a major summit or
meeting of the dominant system and if it in
cludes a strong, well-organised educational
component.
The Battle in Seattle in 1999 was
a massive international protest
against the WTO summit in
Seattle. It was a turning point
in terms of showing that
democracy has avenues other
than elections, and that a
groundswell of well-organised
and well-informed people can
make themselves heard. All
the activists in the Battle in
Seattle recognise that while the
event itself was important, it
will be the continuity of
follow-up that can make a
lasting difference. A follow-up
demonstration took place in
Washington DC coinciding
with the semi-annual meetings
of the World Bank and the
International Monetary Fund
in March 2000.
►
People's Health Assembly
The Chipko 'hug the trees'
movement in India arose
when contractors coming to
cut the village trees of the
Garhwal hills were resisted
by women led by Gaura
Devi. The women hugged
the trees preventing them
form being cut. Later
women in Nabi Kala in the
Doon Valley fighting to safe
guard their water resources
and fields from lime stone
quarry contractors used the
same way of resistance.
Chipko originated 300
years ago in Rajasthan
when Bishnoi community
members hugged the trees
to protect them from being
cut by the King's men and
were killed.
Militant resistance to the
Chico dam. In the Cagayan valley in the Philip
pines, the Kalinga tribal people plant rice on the
steep slopes of the Chico River gorge, which they
have laboriously terraced for thousands of years.
They were not consulted when, in 1967, the IMF
and WB, in collaboration with transnational
companies, started to build a dam that would
flood their ancestral homeland. The people's
formal petitions were unheeded. So they resorted
to civil disobedience led mostly by women.
Repeatedly they removed the tents and equipment
of the dam-building crews, and barricaded the
roads. Women lay down on roads to prevent entry
of big equipment. But soldiers forcefully removed
them and the dam-building began. In desperation,
they dynamited the dam. Finally, in 1987, after 20
years of active resistance, the government called a
halt to the dam-building. Reportedly, this was the
first time that an IMF-WB funded project was
successfull}' stopped by militant opposition on the
part of the people.
Mobilisation of consumers in interna
tional boycotts
Increasingly, consumers are mobilising and
boycotting companies and initiatives that
are unfair or endanger the health of the
people and the environment. These involve
actions from the personal to the global level
and have had an important impact on
companies' behaviour.
e.
At the local level: we will present recom
mendations and experiences of the PHA to
decision-makers at the local and municipal
levels. We will look for support and en
dorsement of the PCH by networks, people's
organisations and concerned individuals.
At the national level: we will support the advo
cacy efforts of local, national and international
people's organisations in the form of lobbying,
campaigning, presentations, discussions, semi
nars, etc. Such efforts can be directed at a broad
range of national institutions, organisations and
companies that have important impacts on
health, as well as at the national offices of tar
geted international and regional institutions and
organisations present in the country.
At the international level: we will join together
with community health-oriented organisations
which are lobbying and putting pressure on
international organisations. For example, WHO,
other UN agencies, funds and programmes,
multilateral and regional development banks
will be lobbied to ensure they promote and
d.wemer
f. Advocacy
A strong advocacy movement has to be one
of the results of the PHA. This network will
be able to express and demand changes
from the local to the international level.
finance comprehensive PHC, assess the effects of
SAPs and health care reforms. We will also
lobby international trade and financial institu
tions and TNCs to develop policies that take into
account and minimise the health and environ
mental consequences.
This section has given just a handful of exam
ples. We cannot begin to do justice to the innu
merable concerned groups that have taken and
are taking action to fight for the people whose
rights are being violated. We only want to stress
that the struggle is not new. But it needs more
strength. PHA joins in filling a space in the
defence of people's health. We are taking on a
big responsibility, we know. But we also know
that there are thousands of you out there who
feel exactly as we do. This initiative can bring all
of us together. Only by acting together do we
have the chance to succeed.
Health in the Era of Globalisation
examples of specific actions
a healthier world
AN EMERGING PHA ACTION PLAN
rawing on this wealth of experiences,
J meth-ods and strategies promoting
9-S change, what should the PHA Action
Plan for a healthier world look like? What are
the important points we should focus on? We
invite you to add to this first, rough version of
an action plan, which we present below. We
hope that in the time leading to the People's
Health Assembly event in Dhaka, there will be
many contributions from all comers of the
world.
1
Living up to the political challenges to
people's health (actions needed)
85 Document the consequences of the SAPs and
the international trade agreements on the
health and well-being of people, their work
ing conditions and the environment.
85 Reassess the neoliberal economic model and
propose viable alternatives.
85 Lobby to place health and well-being as the
objective of development and its measure
ment as an indicator of success or failure of
economic policy.
85 Lobby to make human and environment
sustainable development the objective of
economic policies placing it at the centre of
the discussions on restructuring the Bretton
Woods institutions.
85 Participate in the global campaign to pro
mote fair terms of trade and combat and
prosecute financial speculation.
85 Support the implementation of a tax on
financial transactions (TOBIN tax) and debt
cancellation.
85 Establish a World Sustainable Development
Organisation with power to challenge the
WTO environmental and social values,
which are being violated by a short sighted,
trade-oriented agenda.
85 Support the proposals for a 'People's Cham
ber' in the United Nations.
85 Advocate that all governments assume their
responsibilities and abide international
charters, declarations and conventions.
2
Living up to the social challenges to peo
ple's health (actions needed):
85 Promote and support legislation and pro
grammes that empower women.
85 Support indigenous people in their struggle
for equality, forest, land and water rights.
85 Participate in the fight against corruption, for
accountability and transparency.
85 Develop support mechanisms for families,
including childcare, women's right to work
and workers' right to motherhood.
People's Health Assembly
338 Promote alternative education systems that
foster self-esteem, autonomous thinking and
teaches life skills.
338 Promote a code of ethics for the media
3
Living up to the environmental challenges
to people's health (actions needed):
Lobby for the adoption of the precautionary
principle, which calls for restraint in cases
of uncertainty. Using this principle even the
suspicion of potentially negative conse
quences of a technology or a policy should
motivate restraint and shift the burden of
proof on those in favour of it.
to include health, environmental and social
justice concerns.
338
Develop and implement mechanisms that
favour relevant, environmentally and so
cially appropriate technologies while oppos
ing destructive ones (like genetically ma
nipulated foods, genetically engineered
seeds).
338 Lobby for adequate labelling of consumer
products both in terms of their production
and trade (environmentally and socially
appropriate products) as well as their
potential harm (caution notices on foods and
medicines).
338
Campaign for a redefinition of economic
theory that recognises environmental con
straints.
338
Advocate the curbing of over-consumption,
affluent, unhealthy and unsustainable life
styles both in the North and the South.
Industrial countries in the North should aim,
for on average, a 10-fold reduction of their
consumption and pollutions levels ('Factor
Ten').
338 Support the introduction of tax shifts. These
would increase the tax on the 'bads' (e.g.
energy consumption, waste disposal, pollu
tion, etc) while cutting the taxes on labour,
thereby combating unemployment.
3S8
338
Advocate for the respect of the White
papers on arms trade.
Lobby for the development of accounting
practices that take into account both envi
ronmental and human well-being— both for
national accounting purposes, companies
and public institutions.
Living up to the health sector challenges
and people's health (actions needed):
Assert at national and international levels
health as a central objective for sustainable
development.
Promote the implementation of environmen
tal management systems and their expansion
338
Lobby WHO to assume a stronger advocacy
role in the promotion of health as a develop
ment objective.
Advocate to increase government invest
ment in health at national and international
levels.
Gather and disseminate information that
expose inequities in health and develop
mechanisms to monitor the situation.
Advocate for equity in health and health
care.
Advocate for and promote policies and
projects that emphasise intersectoral actions
for health.
Health in the Era ot Globalisation
:<S Demystify the
causes of illhealth and
promote a better
understanding
of its social
determinants.
338 Expose the
real underlying
structural causes
of ill-health.
to: Promote
comprehensive Primary Health Care as a
model to address priority health prob
lems and organise the health services.
38
Promote community participation in
planning, management and evaluation of
health services.
to:
Reassert the value of community-based
health workers (CHWs).
to:
Promote the use and dissemination of
appropriate health technologies.
38
Foster changes in health personnel
education and health management mak
ing education problem-oriented and
practice- based.
Outlaw secret, not transparent or unethi
cal research.
to:
Notes
1 World Health Organisation. 'World Health Report
1999'. Geneva, Switzerland.
2 UNAIDS. Report on the global HIV/AIDS epi
demic- June 2000.
3 World Health Organisaation. "World Health
Report 2000". Geneva. Switzerland
4 UNDP. 'Human Development Report 1999'. New
York 1999.
5 United Nations Research Institute for Social
Development. 'State of Disarray'. 1995. Geneva.
6 SIPRI Yearbook 1999. Armaments, disarmament
and international security, Oxford University press.
7 See, for example, the 'But Why?' game and the
'Chain of Causes' exercise in PHA's 'Communication
as if people matter' background paper. These exer
cises can be used with specific stories for better
situation analysis.
People’s Health Assembly
The paper you have just read presents
an overview of the situation and is very genera
It is important to know if it is relevant to y<
specific situation and, if so, in what way.
Please let us know what you would like to
added so that your situation is addressed.
We also hope you will contribute your expel
ences in the form of case studies or stories tl
we can use to bring to the PHA specific anal
of different situations; this will stimulate ol
to find their own solutions.
We are particularly looking for experience!
stories that make the links between local prob,
lems and the global economic system, and that
describe people and communities' empowemn^
initiatives that are already under ivay.
Send all your feedback by airmail or E-mail
Nadine Gasman
Fuente de Emperador 28
Tecamachalco C.P. 53950
Estado de Mexico. MEXICO
Telephone: 52-52-510283
Fax:
52-52-512518
e-mail: gasmanna@netmex.com
E?.
Please send feedback by October 10, 2000.
sure to identify the name of your group, yc...
country, the number of participants in your
meeting, and the main characteristics of your
group.
Also please send a summary of the points
discussed during your discussion of this draft
framework.
Finally, please identify and send the main issues
you would like to see included in the People's
Charter for Health.
/oXoXoXoXoX<>X<>X<X<>XoX<X?XoXoXoXoXoX0XoXoX^X<X^
PHA Secretariat
Gonoshasthaya Kendra,
PO Mirzanagar, Savar,
Dhaka 1344, Bangladesh
email: phasec@pha2000.org
website: www.pha2000.org
Printed at Gonomudran Limited. A Project of Gonoshasthaya Kendra Trust, Dhaka-1344. Bangladesh
- Media
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