Public Health, Poverty and Empowerment -- A Challenge

Convocation Address, John Hopkins School of Public Health, l985

David Werner

Those of you receiving a degree in public health are faced with an unusual--and in some ways paradoxical--challenge. For 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. Or, as Mahatma Gandhi put it; There is enough for everyone's need but not for everyone's greed.

It is often argued that the major obstacles to health are economic. And true, for most of the world's people, the underlying cause poor health is poverty--poverty and their 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 all the people, but rather the quest to stay in power.

We are all aware of the health-related inequities that result in millions of premature deaths every year. 1 in 2 of the world's people never in their lives see a trained health worker. 1 in 3 are without clean water to drink. 1 in 4 of the world's children are malnourished. Etc.

It has been estimated that to provide adequate primary health care for all the world's people would cost an extra $50 billon a year--an amount equal to wold military spending every three weerks.

So we can see that the underlying obstacles to primary health care are not really economic, but rather political.

The politics of health and health care are fraught with contradictions. Just as an example, look at smoking. The governments of overdeveloped countries now warn their people that "cigarette smoking is dangerous to your health". Yet these same governments, while cutting back on health benefits to the poor, continue to subsidize the tobacco industry with millions of dollars. And since fewer people in the rich countries now smoke, the big tobacco companies have bolstered their sales campaigns in the Third World, where the growing epidemic of smoking now contributes to more deaths than do most tropical diseases.

The subsidizing of the tobacco industry is but one of many, many ways in which attempts at public health are dissipated by governments that try to stay in power by catering to the interests of the powerful. The United States of America, as one of the world's wealthiest and strongest nations, has consistently made international decisions which favor the rich and powerful at the expense of the health and well-being of the poor majority. Its opposition to the United Nations mandate opposing the unethical promotion of infant milk products is a good example. It is interesting to note that in the long run, the grassroots, popular boycott of Nestle's and other multi-nationals, did more to bring the milk companies into line than did all mandates from the United Nations.

An equally blatant example of how U.S. foreign policy is prepared to obstruct a poor nation's health in order to protect powerful economic interests is seen by its reaction to the Bangladesh Health Ministry's new drug policy. As we all know, overuse and misuse of medications in the
world today has reached epidemic proportions. In poor countries, up to 50% of the health budgets are spent on imported drugs. Of the 25,000 different medications now being promoted, only about 250 are ranked as essential by the World Health Organization. Yet the drug companies promote their products in the poor countries with a vengence. The information they publish about their products in these contries is often dangerously falsified. In many poor contries, the drug companies spend more on brainwashing and misleading the doctors than the medical schools spend on educating them. The companies repeated and illegally pay Ministers of Health under the table to keep on utilizing pharmaceuticals that have been banned in developed countries and dumped on the Third World. All in all, the abuses and false promotion of needless, costly, and irrationally combined medications have reached alarming and health-threatening proportions, particularly in the Third World. When the Bangladeshi government, recognizing serious shortages in 150 essential drugs, passed a decree that banned the import of 1,700 non-essential preparations, the multi-national drug companies did everything in their power to make the Bangladeshi government annul the decree. After all, if a poor country like Bangladesh can take a stand against the multi-nationals in favor of its people's health, might not other nations follow the example? So the multi-nationals began to make threats. Factories would be closed. Foreign companies would pull out. Workers would be fired. Acute shortages of essential drugs would result. The future of foreign investment in Bangladesh would be in jeopardy. Representatives from the US Government not only refused to support Bangladesh's new drug policy, they threatened to reduce or discontinue foreign aid if it were upheld.

As has been demonstrated in China, Cuba, Nicaragua, Kerala State of India, and elsewhere, the health of a nation's people has more to do with fair distribution of resources than with total wealth. Fair distribution, in turn, depends upon egalitarian government. What it comes down to is that the health of the poor in the world today is abysmal because too many governments are in the hands of powerful, elite groups or military juntas, that do not fairly represent their people. Clearly, what is needed is radical change, of governments and social structures. Those who rule the world today will not bring about the changes that are needed for the well-being of the people. They have too much self-interest in maintaining the status quo. The changes can only come about through organized action of the people themselves. In most countries today, primary health care implies a very fundamental, social evolution-if not revolution.

In several countries today, popular revolutions have recently taken place or are in process. New governments with wide popular support have gone about redistributing resources and extending primary health services fairly to all the people. However, the powerful nations of the world, for the same reasons they oppose the UN decree on infant milk products, or the Bangladeshi government's new drug policy, consistently violate international and humanitarian codes in order to try to destroy the revolutionary governments that have dared to side with the people.

Yet the peoples of the world, little by little, are beginning to awaken, to join together to protest the exploits of the powerful, and the injustice which damages their health.

We are on the edge of a worldwide movement, led by the poor and oppressed, in defense of their rights to a fair share of what the world provides. Health for all can only be achieved through a struggle for social equity--a struggle led, not by those on the top, but by those on the bottom, by the people themselves.

Given the fundamentally political nature of health, what are those of you graduating today going to do with your shining new degrees in public health?

If what you are looking for is simply a well-paid respectable job, with a certificate from Johns Hopkins in your pocket you should have no problem. But if you honestly want to help those in greatest need gain the strength and ability to improve their health and their lives in a lasting way, then your future is less certain, and--depending on which country you go to--perhaps unsafe.

You may try to stay out of politics, to work within the realm of public health in the narrower, more conventional sense. Baby weighing, latrines, dark green leafy vegetables, MCH, ORT,
GOBI,and all that.

But be careful. Even with the best intentions, you can easily end up doing more harm than good. Health work is never apolitical. Either it is done in ways that help empower people so that they can take greater control over the factors that determine their health. Or it is done in ways that try to keep people under control, organizationally disabled, overly dependent on centralized, institutionalized, overprofessionalized yet inadequate services.

Thus, health care can be either people empowering in the sense that it gives people greater control over the fators that influence their health and their lives, as well as greater leverage over public institutions and leaders. Or it can be people disempowering, insofar as it is used by the authorities as an instrument of social control. People empowering health care utilizes health education, not to change people's attitudes and behavior, but rather to help people to change their situation. Or, as Pablo Friere would say it, to change their world.

I could talk for a long time about people-supportive and people-oppressive approaches to health care. But a graduation speech is appreciated mostly for its brevity. Therefore I would like to look with you at just one issue in public health, which will perhaps make you reflect on the political implications even in areas that at first glance seem non-political.

The area I refer to is ORT, Oral Rehydration Therapy. (Personally, I prefer to call it RLL or Return-of-Liquid-Lost. This is because most of the world's people have limited schooling and may not underdstand words like "oral" or rehydration, or therapy. I think the first step toward putting health into people's hands is to simplify our language. Besides, RLL -- "The Return of Liquids Lost" sounds friendlier and more poetic.)

I am sure that, in your public health program, you have studied the various alternative approaches to oral rehydration in depth, weighing their comparative advantages and disadvantages. I wonder, however, how much you have looked at the political implications of the different alternatives: which are people-empowering, and which are dependency-creating. For surely the "empowerment factor" shuld always be a key consideration when evaluating the long-term implications of any health care alternatives.

As we all know, when a child has diarrhea, the Return-of-Liquid-Lost can be lifesaving. Insofar as diarrhea is the number one cause of death in children in the world today, oral regydration is one of the most important health measures that mothers, fathers, children, school teachers, and health professionals can learn. Its potential impact on people's health -- and on people's confidence to cope for themselves with one of the world's biggest killers -- is tremendous. It is safe to say that if school children could learn how to prepare and give the "special drink" to their younger brothers and sisters with diarrhea, then the world's children could have a bigger impact on lowering child mortality than do all the doctors and nurses on earth.

As you are will aware, there are two main approaches to oral rehydration therapy: "packets" and "home-mix".

Packets--or "sachets" as they were called by the experts until somebody discovered that not even college graduates understood that word--are prepackaged envelopes of sugar and salts for mixing with a liter of water. Packets are mostly produced in millions by multi-national companies under contract to organizations like WHO, UNICEF, and USAID. They are usually distributed through regional offices to health ministries, clinics, ORT centers, and -- finally --to mothers when their children get diarrhea.

The home-mix, on the other hand, is prepared completely in the home, using local ingredients and traditional measuring methods in order to mix water with the indicated amounts of sugar and salt. Or it can also be made building on local customs, by using rice water, soups, or mild herbal teas.

The relative advantages and disadvantages of packets versus home-mix have been much debated. Studies show that their safety and effectiveness is roughly the same -- provided that the packets are available when needed, which often they are not.

Politically, however, the two methods are diametrically opposite. The use of packets keeps the control of diarrhea medicalized, institutionalized, mystified, and dependency-creating. In order to rehydrate a baby with diarrhea, the family has to depend on a magical, often imported, "medicine" that involves a whole chain of commercial, international, governmental, bureaucratic, professional, and distributional links. If any link of the chain fails, the supply of packets stops. Or if people in the countryside begin to stand up for their rights, the supply of packets stops. Thus, control of the most common, most fatal, most easily treated, health problem is taken out of the people's hands. Poor families are made to look to government for help, and be grateful for small, lifesaving handouts.

The use of the home-mix has just the opposite effect of the packet. It is a de-mystified and de-mystifying approach that is independent of outside resources, except for an initial educational component. It helps people realize that with a little knowledge and no magic medicine whatever, they can save their children from a powerful enemy, without being beholden to anyone. Thus the home-mix helps to liberate people from unnecessary dependency and to build people's self-confidence in their own ability to solve the problems that limit their well-being.

It is no surprise then, that around the world small community-directed programs committed to basic rights consistently choose the home-mix. Nor is it a surprise that WHO, most health ministries, and other large national and international agencies are "packeteers."

At this point I want to put in a good word for UNICEF, which in many ways seems to be more with the real needs of the people and more aware of their potential than is, for example, the World Health Organization. Although UNICEF started with a strong promotion of the packets,

over the last 2 or 3 years, it has moved progressively toward promotion of the home-mix approach to oral rehydration. In some countries, in fact, UNICEF is now promoting primarily the home-mix. I think that UNICEF is to be applauded for this, and that WHO needs to be taken to task for the wide gap between its people-empowering rhetoric and its people-belitting policies at the field level.

Oral rehydration is but one of many hotly debated health issues, which will concern you in the practice of public health. When you are faced with making decisiona or giving advice as to alternative approaches, always remember to look at the political implications. Approaches which are people-empowering, even if they seem to take longer or to involve a greater element of risk or uncertainty, in the long run may do more towars bringing about a healthier, more equitable society, that other methods which appear to be safer, more predictable, more measurable, or more easily administered.

One thing is clear: That health for all will only come about through a restructuring of our social order so that there is a fairer distribution of wealth, resources, and power -- a society where people can learn to live together in peace, where professionals and laborers and farmworkers can embrace each other as equals, where the same standard of living, the same wages, and watch out that no one takes more than his share at someone else's expense.

But, as I have already mentioned, such a restructuring for a healthier social order is not likely to come about from those at the top. It can only come through the organized, united action of those at the bottom.

As health professionals, we are among the fat and fortunate few, the elite of society, the one percent of the world's population with university degrees. Whether we like it or not, we are in some ways part of the problem -- part of the inner circle of a social order that perpetrates poor health. Our challenge, then, is not to try to change the people, or to try to make them more healthy according to our mandates, It is rather to allow the people to change us, to make us lesds greedy, more humble, more able to serve the people on their terms. Our challenge is to help those on the bottom create a new economic and social order in which everyone can afford to be healthy.

I would like to close with a quote from Zafrullah Chowdhury, a doctor who was a freedom fighter in the liberation of Bangladesh, and who subsequently founded Gonoshasthaya Kendra, a community-based health program that has taken many courageous and innovative steps to help empower farmworkers, women, and others who have long been treated unjustly. Zafrullah, incidently, was ofered the post of Minister of Health of Bangladesh, but turned it down, saying that working within the government, his hands would be tied. He felt he could do more to change policy from the outside working directly for and with the people. And in fact, the creation of the Gonoshasthaya People's Pharmaceutical Company to produce low-cost, essential drugs, was a key factor in influencing the Bangladeshi Government to establish the daring drug policy that I mentioned earlier. The following, then, is a quote from Zafrullah Chowdhury.

"Primary health care is generally only lacking when other rights are also being denied. Usually it is only lacking where the greed of some goes unchecked and unrecognized (or unacknowledged) as being the cause. Once primary health is accepted as a human right, then the primary health worker [and, we might say, the public health worker] becomes, first and foremost, a political figure, involved in the life of the community and its integrity. With a sensitivity to the villagers and the community as a whole, he will be better able to diagnose and prescribe. Basically, though, he will bring about the health that is the birthright of the community by facing the more comprehensive political problems of oppression and injustice, ... apathy, and misguided goodwill."

On the road that lies ahead, each of you graduating today will be involved in the struggle for a healthier society. Whether we like to admit it or not, conflicts of interest do exist between those on the top of the social pyramid and those on the bottom. I hope that each of you finds the courage and committment to side with those of the bottom.

What I have tried to say to you this evening with too many words has been summed up far more eloquently by the schoolboys of Barbiana, Italy, poor farmboys who are expelled from school and then helped by a priest to teach each other. This quote is from their book, Letter to a Teacher, which might as fittingly be entitled, Letter To a Public Health Worker. They say:

"Whoever is fond of the comfortable and fortunate stays out of
politics, he does not want anything to change".

But these schoolboys add that:

"To get to know the children of the poor, and to love politics,
are one and the same thing. You cannot love human beings who
are marked by unjust laws, and not work for other laws."

The choice is yours. Good luck.