STRUGGLE FOR HEALTH

Item

Title: STRUGGLE FOR HEALTH
extracted text: Funding for this publication was provided by HIVOS of The Netherlands.
The Globalization and Health Project of IPHC is funded by NOVIB of The
Netherlands.

Introduction
Maria Hamlin Zuniga
(International People’s Health Council)*

Mike Rowson
(Medact and Health Counts)**

The continuing relevance of Alma-Ata
The year 2003 marks the 25th anniversary of one of the most important documents
in international health, the Alma-Ata declaration on Health for AIL The declaration
set a deadline of the year 2000 for achieving a level of health that would enableall of the world’s people to “lead a socially and economically productive life.”
The strategy to achieve the goal would be the implementation of primary health
care, with its emphasis on community participation, and tackling the underlying
causes of diseases, such as poverty, illiteracy, and poor sanitation. The declaration
was drafted by WHO and UNICEF and signed by over 130 health ministers
(including those from the developed countries) and called for a New International
Economic Order to benefit the developing world, and the diversion of money
spent on arms to investments in health. It seems slightly unbelievable today that
rich nations and international agencies could have put their names to such a
radical declaration. However, despite promises, very often the Declaration was
not put into effect: Health for All by the year 2000 was patently not achieved.
But this does not mean we should throw away the Declaration. It has continuing,
and even heightened relevance for the world today. Alma-Ata was an evidence
based Declaration, which sprung from the lessons learnt in the many community
based projects working in health and from the performance of some of the high
achieving developing countries such as Costa Rica, Malaysia, Cuba, China and
Sri Lanka. The emphasis these countries placed on reducing social and economic
inequalities and providing broad based education, health, water and social security
services, showed that good health could be achieved in even very poor countries,
if the political will was in place. Although these problems are challenging,
experience shows that they cannot be ignored.

Challenges
Since Alma-Ata parts of the world have undergone a ‘health reversal’, and many
of the contributions to this booklet show the consequences. Health systems have
come under unprecedented stress, as Dr. Sanders shows in his analysis of the
situation in sub-Saharan Africa. New diseases (and old ones) have flourished,

and public health has deteriorated in many countries. Dr. Unnikrishnan highlights
the intolerable burden that health care costs place on the poor: it is a perverse ■
world in which the actual costs of health care can push people into poverty, but
in many places they routinely do so.

Globalisation and the expanding role of the market have also frequently damaged
health and health care. The new world of free trade in goods and capital has led
to greater instability in the global economy, with dire consequences for health,
as Dr. Monsalvo reveals in his analysis of the Argentinian situation. Global trade
agreements, as Dr. Sanders shows, have prioritized trade concerns over public
health. At a deeper level, the emphasis on introducing markets in health care has
had an unhelpful influence on fundamental values such as co-operation and
.solidarity, and affected the ability of countries to re-distribute income from richer
to poorer segments of society.

Alternatives
Dealing with these global problems, as well as those at the national and
community level is a complex and tiring business for health activists. The
experiences of the Council for Health and Development in the Philippines show
how positive health interventions can be set back by the actions of governments
and the military. However, even in dire situations bravery and tenacity can Win
through. In Latin America, Dr. Monsalvo describes the efforts of health
professionals and others to envisage a new Argentina (and a new world!) through
practical health interventions and policy debate. Dr. Quizphe shows how in
Ecuador, health activists have composed their own ‘Health Charter’ with a list
of demands to government. All such efforts bear testimony to the values
encapsulate in the Alma-Ata Declaration.

All over the world, people concerned with health are trying to focus the attentions
of governments and international agencies on the promises they signed up to 25
years ago in Alma-Ata. Recently, the People’s Health Movement, with which
International People’s Health Council and Health Counts are closely involved,
has been formed to focus attention on these goals and to mobilize activities. We
hope that this booklet will be part of that process and that people concerned with
health will join us in the ongoing struggle for ‘Health for AH’.
* IPHC is a worldwide coalition of people’s health initiatives and socially
progressive groups and movements committed to working for the health and
rights of disadvantaged people - and ultimately of all people. The vision of the
IPHC is to advance toward Health for All—viewing health in the broad sense of
physical, mental, social, economic, and environmental well-being.

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The IPHC maintains that:Hea!th for All can only be achieved through:
participatory democracy - decision-making power by the people, equity - in
terms of equal rights and everyone’s basic needs, and accountability of
government and industry, with strong input by ordinary people in the decisions
that effect their lives.
The International People’s Health Council - IPHC - is one of the groups that
helped to organize and coordinate the People’s Heath Assembly held in
Bangladesh in December of 2000.

If you want to learn more about the IPHC and the People’s Health Movement as
well as future plans for action, please contact:

IPHC Global Coordination
Apartado No. 6152, Managua, Nicaragua
Web site: www.iphcglobal.org
E-mail: info@iphcglobal.org
Fax:(505)266-2225
** Medact is a UK-based organization of health professionals undertaking
education, research and advocacy on the health impacts of conflict, poverty and
environmental degradation. Medact is a member, with the Dutch NGO Wemos
and the Finnish NGO Solidar, of the Health Counts consortium which calls for
economic policies which respect equity and the right to health.
website: www.medact.org e-mail mikerowson@medact.org

CRY MY BELOVED COUNTRY
By Dr. Unnikrishnan PV
The picture below shows Endramaya (60), a migrant casual labourer carrying
on his back his wife, Lakhamma (50), her broken right leg in a plaster cast.
Lakhamma is also a migrant worker, and she was injured in an accident in the
outskirts of Bangalore two weeks earlier. The couple came to the city from Raichur
in the northern dry belt of Karnataka state, where a farm and market crisis make
local people migrate in search of work elsewhere in the country. State capital
Bangalore, one the best technology hubs in the world, “the Silicon Plateau of
India”, is a favourite destination for many migrants.

I was on my way to office when I spotted the couple. Endramaya had already
walked for over two hours along the two km stretch of Mahatma Gandhi Road
in the heart of the city, carrying Lakhamma on his shoulder, occasionally resting
on the roadside.

...

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Endramaya made several attempts to get his wife medical treatment. His first
stop was the government Primary Health Centre (PHC). But the PHC did not
even have the basic facilities to take an X-ray or to put a plaster cast on the
patient's leg. Endramaya then took his wife to several private hospitals and clinics,
but they would not treat her. He did not have enough money to pay.

After several days, once he
was able to mobilise some
money, Endramaya took
Lakhamma to a private
clinic for treatment.
Needless to say, the couple
ended up spending most of
the money they had. They
had just enough for the bus
fare to Raichur. After
treatment, they spent the
night on the pavement and
it was raining. Around
midnight,
Endramaya
started walking towards the Central Bus Station located in the heart of the city.
He walked over 7 km, almost unnoticed in a City that is home to six million
people, thousands of them employees of top firms, including several Fortune
500 companies. He tried several times for a free lift, waving at cars, some of
them latest models, four-wheel drives and auto rickshaws passing by. It did not
work. Perhaps after several days on a hospital trail and a sleepless night he did
not look quite presentable.
Endramaya would walk slowly, after every few yards letting his wife sit on the
kerb, so that he could stretch his hands and try to flag down some vehicle.
Moments later he would continue his journey.

It was morning peak hour. Several vehicles slowed down, those driving them
staring at the couple in disbelief, but they proceeded to catch their deadlines as if
nothing had happened. I was upset and angry. Running towards them, I pulled
my camera out of my backpack. I paused and started clicking. Then they told me
their story. I joined the duo, waving hands at vehicles. Two cars stopped, their
occupants willing to help. We all pooled in some money and helped the couple
get a taxi to the bus station.

That evening at the photo studio I was waiting for the prints to come. A curious
clerk at the cash counter asked me about the photograph. I was still upset, so I
talked a bit loud about it all. Overhearing our conversation, a gentleman patted
me from behind. “It is a good shot, but you should have used a wide-angle lens,”

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the professional photographer said, leaving me speechless. As a medical
professional, I should have told him about the ‘rigor mortis’ of the private sector
health care and the numbness of citizens in general. As a humanitarian
professional. I should have told him that medical expense is the second largest
contributing factor for rural indebtedness in India after dowry, an equally
unacceptable social evil.
A leading national newspaper flashed my photograph of Endramaya’s journey
on the front page of their city edition the following morning. The caption said
how callous the city could be towards its ‘.‘guests” like migrant workers. They
said it was “reality and not virtual,” probably referring to the virtual reality
shows at the city's annual international IT fare that concluded the previous day.
It did not have space to discuss larger issues - mounting medical expenses and
an insensitive health policy that denies even basic facilities to the poor.
A day after the news report, I was giving a class on humanitarian action at a
leading medical college in the city. I waved the newspaper featuring Endramaya’s
journey on the front page. One of the senior students said: “It is a multiple fracture
of tibia and fibula.” Quite a professional remark! By that evening I had one
more professional remark, from a photographer: “It is a very good picture, but
we missed the story.” Sad.

These professional reactions are the signs of our times. The present health care
system has become super-efficient, and it is going fast forward, at least in terms
of technology and innovation. But it has lost touch with social realities, and it is
losing its human element.
By the time you finish reading this note more than 15 people in India will have
died of tuberculosis (TB). Every minute one person dies in India because of TB.
Treating TB is no rocket science. A nutritious diet, sanitation and basic public
education can cut down TB toll. This year we have even seen reports of “alleged
starvation deaths” from two belts in India, a country that has a surplus of food
grains. In a country where a large percentage of women are anemic, this sounds
like a riddle.

Around the same time Endramaya was walking his way of the cross in Bangalore,
experts were discussing the proposed new Health Policy in New Delhi. The last
National Health Policy was announced in 1983. Compared with that, the new
policy draft looks like a sell out. “The new policy (draft) is more eloquent where
it is silent,” says a critique. It omits the very basic concept of comprehensive
and universal health care. For example, one of the salient features of the 1983
document was its commitment to the Alma Ata declaration. It said: “India is
committed to attaining the goal of ‘Health for all by the year 2000 AD’ through
the universal provision of primary health care services.” The new policy (draft)
is silent about it.

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The new policy is also silent about the role of village health workers, the frontier
guards of public health, who keep the pulse of this country ticking. The new
policy has just a few lines about the women’s health, without any specific plans
to improve their health - a betrayal of half the population. The policy does not
care about children. It does not even have a separate section for children’s health
in a country where 70 out of 1000 children die prematurely.
Endramaya’s desperate walk in one of the fastest growing cities in Asia is
symptomatic of the sickness of the health systems in a large part of the developing
world where they fail to cater to the needs of the poor. India’s experience of
dealing with the health needs of its majority, especially the poor, has not been
very impressive. In fact, the health care system has worsened in the last decade,
which has seen comparatively good economic growth.

Critics argue that neo-liberal policies related to trade and commerce, as part
of the World Bank- and IMF-imposed Structural Adjustment Programmes, have
left a long trail of ill health. The cost of medicine, including that of essential
drugs, has shot up. In the last 10 years, the price of drugs used even for killer
diseases like malaria and TB have been decontrolled to boost the health of the
pharmaceutical industry at the cost of human lives. ■
Public health investment in India is one of the lowest in the world and it fell
from 1.3 per cent of the GDP to 0.9 per cent during the 1990s. The new policy
recommends an increase to 2.0 per cent by the 2010. This still falls much short
of the 5.0 per cent benchmark demanded by the People’s Health Movement,
several health and social groups and the WHO long back.
The new draft policy projects that by 2010 public expenditure will be 33 per
cent of the total health expenditure. But even 33 per cent will be lower than the
government expenditure of some of the most privatised health systems in the
world. At present India spends an average of around Rs. 160 (less than US $ 4)
per person per annum on health care. That is roughly the price of three hamburgers,
going by the standards of the new economy. No wonder that Lakhamma had to
go from pillar to post before finding place in a private clinic.

In contrast to the cut in health care sector, the defence budget has shot up. This
is an insult to the people of India, where 200 million people (l/5th of the total
population) do not have access to safe drinking water and 600 million who do
not have access to basic sanitation. Moreover, India pays a huge amount every
year to the World Bank by way of debt servicing - much more than what the
country receives every year. “Our programmes are like medicine. Some of the
medicine has harmful side-effects, and there are real questions about what the
dosage ought to be,” says Michael Mussa, Chief Economist at the International

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Monetary Fund. "‘The best that can be hoped for is that we are prescribing more
or less the right medicine in more or less the right dosage.”
Thebitter pills prescribed by the World Bank have worsened health problems in
many countries. For example, Bank loans for agriculture, dams, mines and power
plants often cause health problems as a side effect of environmental devastation.
Bank-financed dams around the world have increased the incidence of water
borne diseases like malaria and schistosomiasis because the stagnant pools of
water in dam reservoirs breed vectors such as mosquitoes and snails- an additional
burden on the already crippled health system. Further, structural adjustment
programmes have often meant drastic cuts of social safety measures. Often poor
people have ended up paying more for products and services, further cutting
their limited food budget.
As a health and humanitarian worker, my attitude should be positive. I should
explore the possibility of saving and rebuilding lives in disaster, war and epidemic
situations. This note may sound pessimistic. But it reflects the mood of our times.

(Dr Unnikrishnan PV (unnikru@yahoo.com) works on health and humanitarian
issues (disasters, conflicts and wars) with a humanitarian agency in India. He
balances his work with community based humanitarian interventions and policy
research. He is closely associated with the People’s Health Movement and the
International People’s Health Council).

Globalisation, Health and Health Services
in Sub-Saharan Africa1
by Dr. David Sanders
Professor and Director
School of Public Health
University of the Western Cape
Health is in a state of crisis in Sub-Saharan Africa (SSA). While at an aggregate
level health status has improved in SSA over the last fifty years, these
improvements have been slower in SSA than in other regions of the world. For
example, between 1981 and 1999IMR has decreased in SSA from 126 to 107 as
compared with 78 to 57 for the world as a whole. The respective percentages of
decline for this period are 15.1% and 26.9%. Furthermore, in 1999, seven of the
48 SSA countries had a lower life expectancy (LE) than in 1970, while eight
countries have seen an increase in infant mortality rate (IMR) between 1981 and
1999. Life expectancy in 17 of 48 countries has declined between 1981 and
I999123. In addition, young child malnutrition has worsened significantly over
the past decade in SSA4.

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In the past two decades there has been an alarming resurgence and spread of
“old” communicable diseases once thought to be well controlled, for example
cholera, tuberculosis, malaria, yellow fever and trypanosomiasis, while new
epidemics, notably HIV/AIDS, threaten last century s health gains .
To aggravate matters, a number of African countries aie experiencing an
“epidemiological transition”, .with cardiovascular diseases, cancers, diabetes,
other chronic conditions and trauma, replacing communicable diseases in some
social groups, but in others, co-existing with them6.

Access to health services improved considerably during the period 1980 -1990,
but has worsened since then as shown by Expanded Programme on Immunisation
(EPI) coverage data. EPI coverage data for SS A in 1999 show declines in coverage
of all routinely administered antigens7. This occurred despite the intensive polio
vaccination campaigns and the regular measles vaccination campaigns.

The above declines in health status and health sector performance are the result
of the combined impact of economic decline and adjustment, the HIV/AIDS
epidemic which now affects 28 million Africans, approximately 70% of the total
of HIV infected people globally8, and conflict and violence which involves 13
of 48 SSA countries.
The serious economic situation is summed up by the startling statistic that 28 of
48 countries had an average per capita income of less than $1 per day in 1999
compared to 19 of 36 countries in 19819. Furthermore, there is evidence that the
income gap between rich and poor within countries has increased dramatically
over the past decade. In addition, most SSA countries still spend less than an
average of USS 10 per person per year on health care, an amount that is 20-40%
below even that required to cover the basic package of health services advocated
by the World Bank10.

The above situation is the result of a number of factors, some historical and
others contemporary, the latter being ultimately linked to various aspects and
instruments of globalisation.
In Africa, amongst the most important components of the recent phase of
globalisation have been Structural Adjustment Programmes (SAPs), which have
had the effect of;further integrating countries into the global economy through
the imposition of stringent debt repayments and liberalization of trade. SAPs
have also resulted in significant macro-economic policy changes and public sector
restructuring and reduced social provisioning, with negative effects on education,
health and social services for the poor. A recent review of available studies on
structural adjustment and health for a WHO commission states: ‘The majority

10

....

of studies in Africa, whether theoretical or empirical, are negative towards
structural adjustment and its effects on health outcomes’11.
More recently, other instruments of globalisation have further undermined the
ability of developing country governments to provide health care for their
populations. For example, the development of agreements under the World Trade
Organisation (WTO), notably Trade-related Intellectual Property Rights (TRIPS)
and its interpretation by powerful corporate interests and governments, have
already threatened to circumscribe countries’ health policy options. The best
known case relates to the recent legal battle around the attempt by South Africa
to secure pharmaceuticals, especially for HIV/A1DS, at a reduced cost. In 1997
Nelson Mandela signed into legislation a law aimed at lowering drug prices
through “parallel importing’’ - that is importing dings from countries where
they are sold at lower prices - and “compulsory licensing”, which would allow
local companies to manufacture certain drugs, in exchange for royalties. Both
provisions are legal under the TRIPS agreement as all sides agreed that HIV/
AIDS is an emergency. This was confirmed during the WTO meeting in Doha in
2001. The USA administration did not bring its case to the WTO but instead,
acting in concert with the multinational pharmaceutical corporations, brought a
number of pressures (e.g. threats of trade sanctions and legal action) to bear on
the South African Government to rescind the legislation. This followed similar
successful threats against Thailand and Bangladesh12. However, an
uncompromising South African Government, together with a vigorous campaign
mounted by local and international AIDS activists and progressive health NGOs,
forced a climb-down by both the US Government and the multinational
pharmaceutical companies”.
Notwithstanding this important victory, the provisions of the WTO, particularly
TRIPS and the General Agreement on Trade in Services (GATS) hold many
threats for the health and health services of developing countries14.

Accompanying neoliberal reforms of the macro-economy have been health sector
reforms (H.S.R.). Key components of HSR include decentralisation of
management responsibility and/or provision of health care to local level,
improvement of national ministry of health’s functioning, broadening health
financing options through, for example, user fees, insurance schemes and
introduction of managed competition; and rationing of health care through the
identification of public health and clinical “packages”, comprising a set of (often
limited) interventions.

The combined effect of the above interventions together with the impact of HIV/
AIDS on the health workforce has resulted in a significant reduction in public
provision of social (including health) services in SSA, and there is mounting

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evidence of a general decline in access to health services, affecting particularly
the poor This Fs starkly illustrated by immunization coverage, a sensitive marker
of health servicecoverage, which has fallen during the 1990s.15.

In recognition of the growing global health divide between North and South, the
crisis imposed by HIV/AIDS and the resurgence of TB and malaria, as well as
the inability of both for governments and increasingly cash-strapped multilateral
(UN) agencies to invest in health services, a number of Joint Public - Private
Initiatives (JPPIs) have been recently launched. The best-known of these in health
are GAVI (Global Alliance for Vaccines and Immunisation) and the GFATM
(Global Fund Against Aids, Tuberculosis and Malaria).
The first disbursements of the GFATM have still to be made, but those for GAVI,
made for 2000/2001, totaled USD 150 million from initial commitments totaling
USD 1.03 billion. Of this initial disbursement 90% was allocated for the
introduction of new vaccines and single use injection materials, while only 10%
went to strengthen immunization services. Anita Harden has commented: “The
emphasis on the introduction ofnew and under-used vaccines in GAVI reflects a
more general shift awayfrom equity towards technological innovation and disease
eradication in global health programmes. This appears to indicate afundamental
move in vaccine policy from the.values of the Post-Alma Ata (PHC) era. ”16.

Further, it is emblematic of the current emphasis of health policy and the influence
of the private sector partners, that, notwithstanding the clear inability of health
systems - particularly in Africa - to sustain “delivery” of robust, effective and
tested technologies, such as the standard six vaccines, that the focus is on the
pursuit of new technologies, rather than the resuscitation of delivery systems.
Without a shift in currently dominant neoliberal thinking and a consequent change
in macroeconomic policy and its reflection within the health sector, the future
for Africa’s health is bleak.

References
1 UNICEF. State of the World’s Children. 1984. Oxford: Oxford University Press,
1983.

1993ICEF State °f the World’s Children. 1994. Oxford: Oxford University Press,
PrMs^OOO7116 Slate °f the World s Children- 2001. Oxford: Oxford University
ACC/SCN, Nutrition Throughout the Life Cycle, 4,h Report on the World
Nutrition Situation, Geneva, 2000

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5 Sanders D, Primary Health Care 21: “Everybody’s Business”, Commissioned
Directional Paper for an International Meeting to celebrate 20 years after AlmaAta, Almaty, Kazakhstan, 27-28 November 1998, Jointly organised by WHO
Headquarters, Geneva, Switzerland and the WHO Regional Office for Europe,
Copenhagen, Denmark, WHO EIP/OSD/OO.7,

6 Frenk J, Bobadilla JL, Sepulveda J, Lopez Cervantes M. Health Transition in
Middle-income Countries: New Challenges for Health Care. Health Pol Planning
1989;4:29-39.

7

UNICEF. State of the World’s Children, Reports 1984, 1994, 2001 op.cit

8 Collins J, Rau B. AIDS in the Context of Development. Programme on Social
Policy and Development, Paper number 4. Geneva: UNRISD, 2000.

9 UNICEF. The State of the World’s Children. 2001. Oxford: Oxford University
Press, 2000.
10 Simms C, Rowson M, Peattie S. The Bitterest Pill of All. The collapse of
Africa’s health systems. London: Medact/Save the Children Briefing report, 2001.
11 Breman A, Shelton C. Structural adjustment and health: A literature review of
the debate, its role players and the presented empirical evidence. WHO
Commission on Macroeconomics and Health Working Paper WG 6:6. Geneva:
WHO, 2001.

12 Bond P. Globalisation, pharmaceutical pricing, and South African health policy:
Managing confrontation with U.S. firms and politicians. Int J Health Services
1999;29:765-92

13 Hong E. Globalisation and the impact on health: A third world view. Third
World Network, 2000. Available at http://www.twnside.org.sg/health.htm
14

See http://www.preamble.org.

15

UNICEF. State of the World’s Children, Reports 1984, 1994, 2001 op.cit

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Hardon A. 2001 Immunisation for All? HAI Europe, 2001: 6(1).

TAKE TIME GIRLS
By Fortunate Kahari
Mwanza Secondary school
Zimbabwe

Let me take this opportunity
To warn you my fellow sisters, teenage girls.
Before attempting to do anything
Think of the four Ps first
That is Purpose, Plan, Perseverance and Price
Nowadays, there is AIDS.
Do not rush to be parents
Those boyfriends lovers of your are liars
They tell you that they have cars
Where as they are fathers
They tell you that you are as sweet as sugar
But imagine’ girls can you be put into tea
They tell you that your eyes are stars
But do you really know what exactly a star is like
They can even tell you that you are a rose of Sharon.
But why did not they plant you in their gardens.
Take time to know the one you desire in life
Do not rush
And you girls are sometimes foolish
When you hear that, you think that they genuinely love you
But no they are only after your bodies
They are only there to vacate you
You agree to the proposal and have sex with them
After that, they spit you like unsweet bubble gum.
Take time to know what you are doing
Do not rush
Some young girls are involved in such activities
Just because they are blessed at a young age.
Some even, wear cloth that attracts boys
But I tell you; you do not need to show off your body to catch a boy’s eyes.
Their eyes dance every time a boy whistles.
Girls are stopped in streets like commuters.
Girls why not wait like a boutique;

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These are not like flea markets
For many people enter in a flea market and a few in a boutique.
Wait until the right time comes and the right one takes you.
Some of you girls have vanished and come are regretting.
Ignore those silly boys and concentrate with school first, lastly boys

Story of a community health worker from the
Philippines:

Developing Self Reliance in Health
Nang Vicky’s story
Nang Vicky Undangan is a peasant woman from a mountain village in Surigao
del Sur, which is home to landlessfanners in this northwest province ofMindanao
in the Philippines.

When the Community Based Health Program (CBHP) of Tandag reached Nang
Vicky’s community in Camam-onan, San Isidro, she was among those chosen
by her community members to be trained as a community health worker (CHW).
With the existence of CBHP Tandag, the training and developing of CHWs in
Surigao del Sur has been a community effort. Normally, one per 10-15 families
is chosen to be trained as a CHW.
Aside from training CHWs, the health program undertakes community organizing
and health services delivery, which includes assisting referral patients and
conducting medical missions. The trained CHWs are deeply involved in such
activities not only in their communities, but also in nearby communities as needed.

Attending health skills training was never simple for any CHW. This would
mean leaving their children at home, foregoing a day’s work in the farm and
finding extra food to bring and extra money for transportation.

When the CHWs of San Isidro had a 6-day training on Anatomy, Parasitism and
Tuberculosis, Nang Vicky resolved to attend the training at any cost. Only at
that time, the challenge was even harder for her. For three weeks, her husband
then had been suffering from a kidney infection with occasional bouts of vomiting
and fever. The situation made her think twice. She presented her problem to her
family groups, which had offered to look after her husband and children while
she was training.

•••®

•••••©

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The importance of community health services
Nang Vicky finished the scheduled training and went on to serve her community
as a health worker. She belongs to the over 3,000 CHWs of the 57 CBHP
members of the Councilfor Health and Development (CHD). The CBHPs directly
serve marginalized sectors in Philippine society, namely, the peasants, farmers,
fisher folk, workers and indigenous peoples in 2,000 villages spread out in 67
provinces in the Philippines. (The country is comprised of 75 provinces).
Most CHWs like Nang Vicky now recall common experiences of carrying sick
members of their communities in hammocks down die mountain trails for a day
or two to reach help. Most of them suffered from tuberculosis, malaria or diarrhea.
The children were malnourished. People died as they were being brought to the
nearest doctor. These deaths happened because health services were inaccessible
and unaffordable.

They are one in saying that “We have learned so much since that time”. As
products of CBHP training programs, the CHWs have been trained in basic health
skills such as prevention and treatment of common diseases, first aid, use of
herbal medicine, dental hygiene and tooth extraction. And from the basic line of
prevention, the knowledge and skills of the CHWs were raised to a higher level.
They were given trainings on basic anatomy and physiology, history-taking and
physical examination, acupuncture and acupressure. The trained CHWs
multiplied themselves by training new CHWs.

In undertaking such trainings, Nang Vicky, as well as many of her co-community
health workers, are able to find new directions in life after being introduced to
the CBHPs. With limited education and seemingly no hope in the communities
to be employed decently, many of them regain their confidence because they
realize that they can acquire skills that can be of productive use.

Military threats
Many communities of CBHP Tandag were never before visited by government
health care providers. When the whole province was put under massive military
operations against insurgency, soldiers were everywhere in the province—the
town hall, the plaza, the market place and in the fields. People were driven away
from homes and from their sources of livelihood. Women and children alike
were caught in the crossfire.
The CBHP communities, including San Isidro where Nang Vicky lives, became
the subject of undue suspicion from the military and were subjected to tactical
interrogations. The CHWs were also favorite targets for intimidation and
harassment, just like leaders of people’s organizations. The intense military

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harassment demoralized many CBHP communities, forcing the program to cease
its operations.

A decade after, CBHP-Tandag was back on its feet again, working closely with
the diocese of the catholic church. Because of the CBHP’s long and effective
history, there was much work that needed to be done. Memories of the turbulent
period were still poignantly vivid for the communities. However, the tremendous
help the communities have gained from the CBHP outweighed the fear they had
for themselves.

Although, Nang Vicky and the other CHWs of Sari Isidro like Nang Dolor were
met with malicious suspicions and even threats from the military, they were
never afraid to let the military know that they were CHWs. In the case of Nang
Dolor, her regular visitors during those days were not her family groups asking
medical help, but the military looking for subversive documents like her training
manuals in acupuncture, herbal medicines and the likes. Thus, before any military
personnel could rummage through her belongings, she would hide her training
manuals at the back of her house.
After a painstaking period of recovery, CBHP Tandag continues to operate in 33
villages from different municipalities, making people aware of their capacity to
help alleviate their situation by working together as one community. And the
likes of Nang Vicky, Nang Dolor and the rest of the CHWs have once again
proven their worth as many times before in contributing their share in developing
self reliance for an alternative health care system that CBHPs promote.
The story of Nang Vicky and CBHP Tandag that she worked with is only
reflective of what is now 29 years experience of CBHPs in the Philippines.
Evolving from the first mobile-paramedic training health team in the 1970s to
actually laying the foundation for an alternative health care system, CBHPs
continue to survive and thrive because they are rooted in a very strong and solid
foundation—the people of the community who struggle unceasingly to defend
their lives and rights, and to develop their own appropriate health programs. —
[Council for Health and Development, 04 November 2002, Quezon City,
Philippines].

••••

17

Argentina 2002
Endemic Injustice and Silent

Proposals from Daily Life
By Dr. Julio Monsalvo
Argentine doctor and activist of the peoples Health Movement

“Microbes are insignificant as a cause of disease compared to the illnesses that
cause poverty, the social despair, anguish and misfortune ofpeoples. ”
Ramon Carrillo (first Minister of Public Health of the Argentine Nation, 1945-52)

The growth of hunger
Angela lives in a poor neighborhood in one of Argentina’s large cities. She is 39
years old, mother of four children. In the “Health Center,” a young doctor,
Alejandra, diagnoses that Angela has anemia. The cause is quite clear. She lacks
access to adequate nutrition. Angela is one of nine women over age 35 who have
been diagnosed with anemia this week, all due to the same cause. A simple test
shows that Angela barely has 8 grams of hemoglobin, as well as low levels of
red cells.
.

In this Health Center, as in. most Argentine hospitals, medications with iron
supplements have not been supplied for quite some time. This is happening
throughout the country, anemia is being detected in all age groups due to a lack
of access to food. Numbers are growing of malnourished and anemic children
(particularly under age 5), anemic pregnant women, anemic children with low
birth weight, and malnourished elderly people. In one province alone, official
2001 data showed 71 deaths from malnutrition, of which 44 were children under
age 5 (62%) and 21 people over age 50 (30%).

But our young doctor does not become discouraged. She researches what local
plants may be a source of iron and discovers “nettle” (Urticara urens L.) She
prepares a nettle tincture in the Health Center and gives Angela this natural
treatment for three weeks. The test results improve and Angela feels much better.
This encourages Alejandra and other health workers to treat the other women
with nettle tincture. The results were successful and the word of the solution
spreads. It’s an uphill struggle, but also heroic and hopeful. Bit by bit, spread
from mouth to mouth, people begin to talk about this possible treatment.

18

An abundance of food
Argentina annually produces, according to official data, 68 million tons of food.
With a population of 35 million, there would be an abundance of food if this
were deemed a social good and the production of food was aimed at feeding
people instead of increasing the profits of a few corporations. Each person would
have 2 tons of food per year, five and a half kilograms per day. Even part of that
food would take care of the country’s needs, and the system could keep exporting
the rest. Instead, over half of the population is living in poverty or outright
indigence.

In addition, there are concerns about food quality. Argentina is one of the countries
“with a large area dedicated to growing genetically modified foods. The use-of
agrochemicals not only contaminates food sources and soil, but also leads to
poisoning and deaths. Animals are subjected to cruelty, fed unnaturally to be
fattened quicker, in order to produce “increased economic benefits.” The industry
uses an abundance of chemicals for coloring, as preservatives, and “authorized”
flavoring. On top of the injustice that the great majority is denied the right to
feed themselves, we now have food insecurity in a country that has lost its food
sovereignty among its many other losses.

Another Argentina, another world
Alejandra, the young doctor in our story, is one of thousands of health workers
in this country who silently struggle every day to provide humanitarian answers
to pain and misery. At the same time proposals are being made to build a different
Argentina!
For many years in cities there has been a food production for consumption
program called “Prohuerta.” The State provides seeds for vegetables and fruit
and farm animals, in addition to training for organic-style production (no
agrochemicals or chemical fertilizers are used). Between large cities and smaller
communities, up to 400,000 family, school and community garden plots have
been registered. These produce about 80,000 tons of food per year for 2.5 million
people. It is estimated that the country has 7.5 million indigent people. Instead
of supporting and broadening this program, the budget allocated for it has been
reduced by 7%. Other State and NGO programs also help people feed themselves.
However, these efforts are not encouraged or supported by the State.
Here and there, throughout the country, small groups of women and men farmers
produce events with incredible political and transformational voltage, fairs to

19

exchange seeds from local production and establishing local markets with organic
products. There are many examples of healthy food production systems, social
and economic organizations based on respect for all forms of life, which translates
into healthy relations with the ecosystem that have a positive impact on health.

A change in paradigm and in consumption patterns is urgently needed to roll
back the endemic social injustice and immediately bring an end to all cruelty
and the denial of access to foods and healthy foods.

Over 50 years ago Ramon Carrillo pointed out that social injustice was the cause
of illness. Today in Argentina those social injustices have deepened and spread,
and have become ecological injustices in the form of soil deterioration, the
disappearance of forests, contamination of rivers and the air. For many years in
this country, women fanners, professionals and students committed to health
and life have been proving that it is possible to create another Argentina, and
another world as well.

Mandate to the new Government

Health for all: Essence of a good
Government
Dr. Arturo Quizhpe Peralta
Dean of the Medical School of the University of Cuenca-Ecuador
Coordinator of the International Peoples Health Council, IPHC-South America
“Equity, ecologically sustainable development and peace, are the central
focus of our vision of a better world. A world in which a healthy life for all
becomes a reality; a world that respects, appreciates and celebrates all life
and diversity; a world that allows the flourishing of talents and abilities to
enrich all of us; a world in which the voices of the people guide the decisions
that affect our lives. More than enough resources are available to achieve
this vision.” (1)

A sick society
The neoliberal development model in effect is not sustainable; its failure has
been extensively proven in countries like Argentina. It cannot even be considered
as a model of development, as it is designed to perpetuate underdevelopment
and strengthen dependency. We survive in a sick society in which humans have

20

been sacrificed for the market, where nature is profaned and attacked by the
greedy interests of large transnational corporations, where the abuse of power,
corruption, intolerance, segregation and injustice rule.
We cannot go on with more deceit and white lies. Health is intimately connected
to development, and development in turn, produces health. One cannot speak of
health policies for the majority if this does not go hand in hand with an integral
reform of the State aimed at the well being of the majority. As Dr. Roses, the
new Director of PAHO, has stated: health programs are a reflection of a country’s
ethical decisions, they reflect the value given to life and human development in
general, and even more specifically, the value of the life of each human being,
of women and children, of the disabled and elderly.

Poverty must be eradicated
In Ecuador and the other countries of Latin America, poverty constitutes the
main cause of illness and death, and therefore its roots are found in the economic
and social policies imposed upon us.

Poverty arises from the inequitable distribution of wealth, the society’s
organizational structure, the unequal trade between nations, the exaggerated
power of transnational corporations, and the policies they impose to increase
their profits.
As stated in the People’s Charter for Health: “economic globalization and
privatization have deeply disrupted communities, families and cultures. Public
institutions have been undermined and weakened; many of their responsibilities
have been transferred to the private sectors, to corporations or other national and
international institutions that rarely lake on responsibility before the people.”

Poverty must be eradicated, not lessened. Attempting to lessen poverty means
treating the-symptoms instead of the disease. Fighting poverty means
redistributing wealth, working for more just rules of trade, generating
employment, allocating resources, responsibility and power to the people.

All the countries in the region have included health in their constitutions as a
right of all people. However, expenditures on health have been determined and
subjected to economic calculations, the decisions of transnational corporations,
and market interests, sacrificing the life of millions of men, women, children,
and elders.
Human development indicators reflect a degrading reality for human beings:
80% of Ecuadorian homes are poor; 20% are indigent, with no access to education,
social security, or basic sanitary infrastructure; maternal mortality (160 to 300

.... .......................’............. .. 21

for 100 000 live births) and infant mortality (39 out of 1000) are high and result
from preventable causes, the persistence of illnesses associated with poverty
such as dengue fever, malaria, yellow fever, tuberculosis, and others.

A variety of organizations and groups from towns in Ecuador working in this
area and committed to the struggle for the respect and full effectiveness of this
primordial human right, appropriate as our own the points of the People’s’Charter
for Health and set forth the following:

Basic Principles for a Program of Health for all
• Guarantee the universal access to high quality integrated Primary Health Care,
according to the needs of the population, not their ability to pay.
• Elimination of cost-effectiveness criteria as a defining factor for the
implementation of health care programs and the abolition of cost recovery
projects because they generate inequity and obstacles to access to services.

• Stop privatization of public health and social security services, ensuring the
effective regulation of the private medical sector including medical charities
and NGOs.
• Increase public investment to at least 70% of the national expenditure on health.
• Emphasize the promotion of health, primarily in community organization and
participation.

Strengthen and legally support social participation, intersectoral work, and a
multidisciplinary approach to health problems.

• Promote health programs aimed at women, the eradication of domestic violence
and fulfillment of the Law of Free Maternity.
Establish promotion and prevention programs for the health of young people,
particularly related to sexual and reproductive rights.
• Adopt measures to ensure occupational health and safety that include oversight
o working conditions, particularly for high-risk sectors (for example: assembly
p ants, flower growing companies, the informal sector and others).
• Regulation of the use of technologies, production and issue of medications, to
assure they are subordinate to the needs of the population.

That research on health - including genetic research and the development of

repro uctive medicines and technologies - be oriented towards people and
public health and respect universal ethical principles.

22

.

• To defend harmony with the environment and the protection of ecosystems.
• Invest more, invest better and begin to pay the social debt, giving priority to
health and education, reducing military expenditures and payment on the
foreign debt.

• Submit economic policies to assessment regarding their health, equity, gender
and environmental impact and include regulatory measures to follow-up on
their fulfillment.
Health is a fundamental human right, and this is why we tell, beg, and
demand that the new government make a serious commitment to Health
for All.

Cuenca, November 2002
(1) People’s Charter for Health. IPHC. December 2000.

1 * This Policy Brief draws heavily upon: Sanders D., D. Dovlo, W. Meeus, U.
Lehmann, “ Public Health in Africa ” in Global Public Health, R. Beaglehole
(ed.), O.U.P (forthcoming)

PROBLEMS AND SOLUTIONS

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