Empowerment and Health

Prepared for a forthcoming booklet by the International People's Health Council

Talk given by David Werner
Christian Medical Commission/CCPD Joint Commission Meeting
Manila, Philippines, 12-19 January 1988

How important is empowerment to achieving 'health for all'? Extremely important! In reality, health depends more on empowerment of and by the people than it does on health care per se.

Yet, when I was invited to speak on 'empowerment' I had misgivings.

For when words become jargon they lose their power. The term 'empowerment', which in its fullest sense is a liberating grassroots concept involving confrontation, has now been so sanitized and depoliticized by the health and development establishment that it has become more pacifying than liberating. We have all but forgotten its political roots in poder popular or power by the people.

I would argue that if the concept of empowerment is to have significant impact on die health of the world's poor majority, it must be viewed as a political process - with a sociopolitical goal: the equalizing of power and basic rights.

We are all aware of the health-related inequities that result in millions of unnecessary deaths every year. Half of the world's people never see a trained health worker. One-third are without clean water to drink. One-fourth of the world's children are malnourished. Yet, the world's leaders spend $50 billion every three weeks on the instruments of war - an amount that could provide health care to every one on earth for an entire year.

As we all know, in today's world the biggest obstacles to 'health for all' are not technical, but rather social and political. Widespread hunger and poor health do not result from total scarcity of resources or from overpopulation, as was once thought. Rather they result from unfair distribution of land, resources, knowledge, and power - too much in the hands of too few.

It is often argued that the major obstacles to health are economic. And true, for most of the world's people, the root cause of poor health is poverty - and the people's powerlessness to do anything about it. Yet the economic resources to do something about it do exist. Unfortunately, control over those resources is in the hands of local, national, and world leaders, whose first priority too often is not the well-being of the people, but rather to stay in power.

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Empowerment is the process by which disadvantaged people work together to increase control over events that determine their lives. It is a personal and group process combined. Too often you hear planners saying "We need to empower people to do this or that." But the very idea that you or I can empower someone else contradicts the process of empowerment, which is something people do for themselves.

Power cannot be given or taught. It must be taken. However, we who would seek a healthier world can sometimes help facilitate or open the way for people to empower themselves. Perhaps the best way to do this is to join in solidarity with disadvantaged groups, on their terms, and to participate in their struggle for greater control.

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Primary health care, as described in the Alma Ata Declaration of 1978, is a comprehensive process whereby people work together to improve the total situation of communities, and to deal with the underlying causes of poor health. It fully recognizes that, "Basic changes are needed in the social and economic situation of the poor majority," and that, "such changes are related to issues of social justice, equal access to available resources, and just return for the work that people do."

T'his means that primmy health care, to be effective, encourages people to take positive action for their own well-being. It can start small, but necessarily evolves and expands to cover more and more basic factors affecting people's lives.

For example, by learning how to prepare and give to a child with diarrhea adequate drink and food in the home, people can gain a little more control over the main cause of death in children. This can help them gain confidence in their ability to change events that affect life and health.

However, people need to realize that oral rehydration although very important, is a stopgap measure. At best, it can reduce the death rate from diarrhea by about 50%, which is still far from acceptable. Mortality from diarrhea in children in the world's poorest communities is 200 times higher than that in Sweden or Holland.

High mortality from diarrhea cannot be adequately resolved until we squarely confront its underlying causes.

Just as death from diarrhea is determined, to a large extent, by socioeconomic factors, the same is true for most of the other major health problems affecting the poor. Thus, primary health care - if it truly involves the people in seeking solutions for themselves - creates a demand for fairer social structures. The primary health worker who earnestly works with people and learns from them the obstacles to health, will necessarily become politicized. Thus the community health worker can become "an internal agent of change, not only for health care, but for the awakening of his or her people to their human potential and ultimately to their human rights."

Today, it is often said that primary health care is an experiment that was tried and failed. But in most countries, it has never really been tried, at least by the governments. Is this not because primary health care has a liberating and empowering potential? By helping people gain control over some aspects of their lives it can catalyze collective action for social change. In its fullest sense, primary health care is, indeed, revolutionary. It is no surprise, therefore that in most countries, primary health care has not been allowed to succeed. The very few countries where governments have given it a fair chance are mostly those where social transformation has recently taken place. But, in most countries, true comprehensive primary health care has been opposed indirectly or directly in a number of ways.

Many countries that officially subscribed to the Alma Ata Declaration introduced so-called primary health care 'packages' that were, in fact, centrally and rigidly controlled. Rather than help people take greater charge of the issues concerning their health, they created more dependency on outside supplies, services, and regulations. Participation, although much touted, was often reduced to required volunteer labor. The role and functions of the village health worker were narrowly limited to a few preventive and even fewer curative functions. Such a model of health care does little to empower or build confidence in anybody. Rather it reinforces centralized power and social control.

In countries where the gap between rich and poor is enormous, and where those holding power use strong-arm tactics, the extremes of poverty and oppression can actually catalyze the process of social awakening. In such countries religious groups, nongovernment organizations, and popular movements have often promoted community health and development initiatives to help the poor cope with their needs. Many of thse self-help initiatives began from a humanitarian, politically naive perspective. But injustice undermining people's well-being was so blatant that they evolved into collectives of people demanding and strategically working for their rights. In short, nongovernment community health programs and workers more often became the focal points of community organization, which has helped both to foster and to strengthen popular movements for social transformation.

In response, governments have often reacted repressively and even violently. In Nicaragua under the dictator Somoza, and in the Philippines under Marcos - as in Chile, Guatemala, Honduras, and El Salvador today - a major attempt was made to suppress people-centered health programs or to absorb them into the centrally-controlled, government 'primary health care' schemes. Village health workers in nongovernment programs have often become special targets of attacks, torture and disappearances.

In Nicaragua today, by contrast, health posts and health workers are a chief target of the U.S. government-sponsored Contras. Similarly, in Mozambique, health posts and health workers are targets of the RENAMO terrorists sponsored by the apartheid South African government.

Repressive governments do have good reason to fear the empowering potential of community-directed health care initiatives. In Nicaragua, the process of 'conscientización' and community action initiated through nongovemment health programs played a key part in the mobilization of the people that led to the overthrow of Somoza. Likewise, in the Philippines, the process of 'structural analysis' and collective action widely promoted by scores of 'community-based health programs' played a critical role in the empowerment of the people to where they were able to rise up and peacefully oust the dictator Marcos.

So we see that primary health care, when it is allowed to become a truly people-centered process (and sometimes even when it is officially not allowed) can be a powerful and empowering process which can help unite, educate, and activate the people in the struggle for health.

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Perhaps the biggest threat to primary health cue as an empowering process has come about in the 1980's in relation to the so-called 'adjustment policies' imposed, to a large extent, by the international banking system and precipitated by the current world economic crisis. The massive foreign debts and suffocating interest payments which most Third World countries have fallen prey to during the 80's have forced these poor countries into an even more powerless and dependent position. As part of 'adjustment', the poor countries have been required to increase production for export (rather than for local consumption), to freeze wages and free prices, and to limit public spending. These adjustment measures, while they may permit poor countries to keep servicing their huge debts, have resulted in increasing malnutrition and child mortality and cutbacks in available health services.

At the last global policy planning meeting of UNICEF, I nearly wept to witness the way in which its spokespersons carefully analyzed, and then accepted as inevitable, the increasingly unjust world economic order of the eighties, with its debilitating adjustment measures. UNICEF analysts predict that this devastating situation will continue unabated through the nineties.

Therefore, feeling powerless to do anything about the root causes, UNICEF has proposed a variety of alternative measures, including its own 'adjustment policy' for health care. In essence, it has sacrificed the potentially liberating concept of 'comprehensive primary health care' and replaced it with 'selective primary health care', under the name of 'GOBI' or the 'Child Survival and Development Revolution'. Some critics have described this as the "revolution that isn't," for by focusing on a few 'cost effective' technological interventions (now mainly immunization and oral rehydration) it falls far short of the empowering process implicit in comprehensive primary health cue. Indeed it tends to neglect, and in some cases undermine the basis of primary health cue, which calls for a truly revolutionary mobilization of people in the struggle for a healthier, more just social and economic order.

It is important that the Christian Medical Commission and any other groups that are genuinely concerned for the well-being, rights and overall health of the people carefully examine the full implications of selective primary health care and the Child Survival Revolution. All NGOs should think very carefully before jumping on this bandwagon.

Selective primary health care is in many ways a major step backward in the process of trying to get at the root pmblems affecting the health of the world's poor majority. As the health statistics of the 80's progressively worsen in many countries, advocates of selective primary care argue that there is no longer the time nor money available to implement a comprehensive approach. Rather, they have decided to focus on a few cost-effective interventions that can fairly quickly reduce mortality of high risk groups, and which neither require nor promote fairer social structures.

Immunization and oral rehydration are very important, and can save many children's lives, at least temporarily. But we must remember that the children who die most from diarrhea are the most poorly nourished. Therefore, if we focus on saving children's lives with CRT without adequately combating the causes of the poverty and malnutrition, both the number and proportion of malnourished children may increase in accordance with the success of CRT programs. Ironically the net result of all our efforts in CRT - and also immunization - may actually worsen the quality of life of many of the world's children. This distressing trend is now being documented in some countries.

We all agree that children's lives should be saved wherever possible. But survival is not enough. If quality of life is to be improved, it is essential that ORT, immunizations, and the other high priority interventions, be integrated into people-centered approaches which are part of a global struggle for the redistribution of resources and power.

I would like to stress that the difficulty with selective primary health cue is not so much that it concentrates on a few priority interventions. Any problem-solving approach considers priorities. Rather the difficulty lies in who decides the priorities, who controls the selected interventions, and they ways in which they are implemented.

In evaluating any health or development strategy, we must always ask ourselves, "How much are the people actively involved and empowered? In what ways do the methods used help or hinder the long term process of combating the social, economic, and political causes of ill health."

Too often selective primary health care as it is now implemented (in spite of all its fuzzy rhetoric about participation, mobilization, and empowerment) places more decisions and control in the hands of central authorities, businessmen, and even foreign 'experts'. Rather than promote greater equity, too often it further entrenches and legitimizes the existing inequitable power structure.

In some of the most repressive countries, soldiers and security police have been 'mobilized' to participate in mass immunization campaigns. In effect, this upholds and covers up 'in sheep's clothing' the very forces that perpetuate injustice and poor health. Fewer children may die of measles and diarrhea today. But what does this mean for tomorrow?

Rather than choosing alternatives that increase self-reliance' the controllers of selective primary health care too often opt for alternatives that create greater dependency.

Thus we see that government oral rehydration programs almost invariably choose ORS packets over 'home mix'. This is unfortunate. Not only do cereal-based home mixes have the potential of saving more children's lives with less risk and at lower cost than do the sugar-based packets; they also put management of the major killer of children squarely in the people's hands.

Agreed, there is still much debate about the relative advantages and disadvantages of the different ORT alternatives. But are the families whose children’s lives are at stake given the chance and information to effectively take part in this debate? Or to decide for themselves?

In selective primary health care the 'experts' make all the major decisions. But not always, it seems, in the children's or families' best interests. For the experts are pressured and influenced by current trends in international development Thus we see a recent move in many countries toward privatization and commercial distribution of ORS packets. As a result in some countries, families have to pay nearly a day's wages for a single packet. And so, (where 'social marketing' has been successful), a family willingly spends its whole day's food allowance for one magic packet.

This is but one of many reasons why most national ORT campaigns have fallen far short of the predicted results.

Selective primary health care, with its focus largely on technical interventions, on products rather than process, on survival rather than quality of life, on social marketing rather than awareness raising, on compliance rather than true participation, on private enterprise rather than collective action, and on courting the support of NGOs, government institutions and public figures rather than that of the poor majority, fits in well with the current shift to the right in the West with its attempt to impose a profiteering ideology on the entire world.

If we are ever to have a healthy and a sane society, the disadvantaged and oppressed of the world - the women, blacks, harijans, disabled people, the urban and rural poor - must be joined by those of us, the educated, the comfortable, the elite, who nevertheless have a human conscience and the will to social justice. We must all join together at the community, country, and world levels, North and South, to work toward forging a more just society with leaders who truly serve the people.

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By looking at the process of empowerment of and by marginalized people we can learn something about strategies and methods that seem to work. Then perhaps we can begin to apply these to the larger solidarity movement at national and international levels.

There is no pat formula for empowerment. It happens in many ways. It is a cyclical process leading from increased personal understanding to group action. People often seem apathetic or feel powerless because they temporarily lack the awareness, confidence, and competence to take action leading to change. Paulo Freire formulated one of the early strategies of empowerment, by bringing together small groups of people in squatter settlements, to 1) discuss problems; 2) analyze causes; and 3) formulate strategies to confront oppressive forces in society. After reflection, the process is then repeated.

As the number of involved people grows, along with their experience and sense of strength, the group can begin to take on more difficult, underlying problems. But risks must be weighed against benefits. Conflicts of interest between those on top and those on the bottom in the community need to be clearly defined. Strategies for action try to bring about the greatest benefit with the least harm. Any attempt at equalization of power or rights involves an element of danger. In fairness, this needs to be discussed by all participants.

Mass mobilization is critical. To avoid being crushed by those in power, the marginalized group that is struggling for greater control needs to recruit as many supporters as possible. It should try to get a substantial majority of like persons actively mobilized in support of the movement. If a strong majority of the community is mobilized, the powers that be may be more hesitant to take repressive or violent action.

As marginalized groups unite and try to bring about more fundamental changes, the risk of repression increases. In the early stages, land owners may employ local thugs to put down land invasions. As the movement grows, the army or security police may be called in. And if the people's movement grows too strong, this may lead to outside intervention from more powerful countries that have economic or military interests in maintaining the inequity of the status quo. Especially where repression is severe, there is a need for a coalition, or agreement of mutual support, among community-controlled health and development action groups.

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Much of what I have been saying up to now has been rhetorical, and I apologize. I would like to give an example of how a community health program, directed by local villagers, evolved into an empowering process whereby poor farming families have organized and managed to take control over a number of the events that previously kept them in poverty and poor health. The program I speak of is Project Piaxtla in the mountains of western Mexico.

It is run completely by local villagers. When it started 23 years ago, the health of many people was poor. Thirty-four percent of children died in the first five years of life, primarily from diarrhea and infectious diseases. Seventy percent of women were visibly anemic and about ten percent died during or after childbirth.

Although most families were very poor, there were a few wealthy land and cattle owners. Constitutionally after the last Mexican revolution, the good river bottom land held by these few rich families should have been redistributed. But due to corruption of the land reform authorities, the rich had managed not only to maintain but also to increase their large holdings. Poor families had no choice other than to sharecrop for the rich or to subsist by slash and burn farming of the steep hillsides.

Occasionally some of the poor farmers had tried to demand their rights or take over some of the good land. But the rich kept the poor divided. Whenever poor families tried to organize, their leaders were killed and their efforts thwarted. Although decisions in the community were officially supposed to be democratic, in fact, the few wealthy families completely controlled both the meetings and the votes, where disputes were invariably decided in favor of the rich.

This was the situation when the health program began in 1965. The program started naively, without any political objectives other than that it should serve and be controlled by the poor. It began with a focus on curative care, which was what people felt they wanted. Village health workers were trained using non-formal participatory methods.

As people became more skilled in curative self-care, they grew more aware that the same illnesses often reappeared with alarming frequency. So the focus of the pmgram gradually shifted to preventive measures: vaccinations, latrines, water systems, etc. As a result, there was some improvement in health. Nevertheless, there were still many malnourished and sick women and children, particularly in years when harvests were poor. The main reason seemed to be poverty. The rich had endless ways of exploiting the poor. These were discussed. Finally people began to organize and take action to fight exploitation and improve their economic base.

One of their first actions was to combat the usurious loan system. By the beginning of the planting season, poor farmers would ran out of stored maize and were forced to borrow from the rich. For every sack of maize loaned they had later to return three sacks. After payment, many families had almost no grain left. And if they couldn't pay, the rich would strip their homes of all their possessions. As a result, many families had to migrate to the city slums.

To combat this situation, the village health team helped the poor organize cooperative maize banks which now function in five villages. These maize banks improved the economy and therefore nutrition and health of many families. They also helped bring about greater cooperation, accountability, and organizational skills to groups of poor farmers. People began to gain confidence in their own ability to improve their situation. The organization of poor farm workers in the central village of Ajoya grew to where the workers were able to take control of the community council, formerly controlled by the rich.

Next, poor farm workers began to organize collectively to fence land to keep the cattle of the rich from eating their mountainside crops. Before, they had had to borrow from the rich for fencing and perpetually forfeit the grazing rights in exchange. Now they were able to rent the grazing rights to the rich. Their economic base - and sense of their power to bring about change - continued to grow.

Then the farm workers began to take over the river bottom land illegally held by the rich. When the land reform authorities at the state level refused to back them, they sent a committee to the Ministry of Land Reform in Mexico City. The farm workers hounded the offices for two weeks until at last orders were passed down to state level to comply with their demands.

To date, the farm workers have managed to repossess nearly half of the good river bottom land. This year, aided by some outside 'seed money' to buy a pump, they have begun to irrigate their land in the dry season, so that they are now able to double the number of crops per year. As a result, the people are able to eat better, and to save some money for medical and other emergencies. Child and maternal mortality continue to decline.

The women have also begun to discover and exercise their power. Drinking of alcoholic beverages has long been a major cause of violence among men, and of hardship and hunger for the women and children of the men who drink. Because of the violence, the public bars in Ajoya were closed down many years ago. But in 1982, the municipal president decided to open a bar for his personal profit. The village health workers helped the women to organize and protest the opening of the bar. Although six of the health workers were temporarily jailed, the women finally succeeded in closing the bar.

Project Piaxtla has also given birth to a sister program, called PROJIMO, run for and by disabled persons. 'The team of disabled rehabilitation workers are also going through their own process of empowerment. They insist that they do not want to be 'normalized' into a society which so often is unfair or unkind to persons who are in any way different or weaker than others. As disabled people, they feel they would rather join together with all who are treated unfairly, to work for a new social order that is kinder, more just, and mom sane.

As the Piaxtla program has evolved, some of the village team have had the opportunity to visit other community-directed programs in Mexico, Central America, and as far away as the Philippines, India, and Bangladesh. They have helped forge a solidarity with 'those on the bottom' in various parts of the world.

In conclusion, Project Piaxtla and the farm workers organization that grew out of it have initiated a process of empowerment which locally has had a limited but significant impact. For example, the death rate of children has dropped from 34 to 7 percent. Yet the activist team knows it is playing with fire. Health workers and members of the farm workers organization have repeatedly been jailed or threatened. In a sister program higher in the far side of the mountains, two of the health workers were killed by state police for trying to organize people over their timber rights.

The village workers realize that from one day to the next, they may face severe repression. Attempts have been made to close the program down. There have also been efforts to make the village program redundant by the introduction of one government health program after another into the area (rather than into areas where there are no health services at all). But whatever the future for the individual program, the participants realize that they are part of a much larger process.

In the world today, it has become increasingly clear that the struggles for health, development, and social justice, even in a remote village or slum, are inseparable from the global struggle for a more just world economic and social order. Poor people in a single village will not gain control over the factors that determine their health and lives, until they join together with many others to bring about transformations at the national level. Similarly, a single poor country that tries to answer to the needs of its people through advancing a more egalitarian system, will find that certain powerful nations try to prevent it from succeeding. Just as the poor people in a village can find strength through unity, so the more progressive poor nations must join together and take a stand against their exploiters. For such a stand to have any hope of success, developed nations whose leaders have more of a social conscience must stand behind the peoples of poor countries to form a coalition of solidarity. This coalition must try to restructure, realign, and help empower the United Nations, including UNICEF, WHO, and the World Court, to take a strong stand on opposing the unjust international economic order, the health-destroying 'adjustment' mandates and other policies that aggravate poverty and poor health - even if this means defying the United States' government and its allies, and therefore operating on half their present budgets.

The agencies which have created the slogan of 'Health for All' must not be allowed to acquiesce and adjust to the unjust and unhealthy world economic order. Rather everybody in the world who wants to see poor children get enough to eat should join together to form an international movement against exploitation and for social justice. Only then will empowerment of and by the people forge the way for lasting improvements in health.

The Christian Medical Commission can be an active promoter and voice of conscience in this process.