Where There Is No Doctor: A Village Health Care Handbook

Contents and Purpose

This handbook has been written primarily for those who live far from medical centers, in places where there is no doctor. But even where there are doctors, people can and should take the lead in their own health care. So this book is .for everyone who cares. It has been written in the belief that:

1. Health care is not only everyone’s right, but everyone’s responsibility.

2. Informed self-care should be the main goal of any health program or activity.

3. Ordinary people provided with clear, simple information can prevent and treat most common health problems in their own homes-earlier, cheaper, and often better than can doctors.

4. Medical knowledge should not be the guarded secret of a select few, but should be freely shared by everyone.

5. People with little formal education can be trusted as much as those with a lot. And they are just as smart.

6. Basic health care should not be delivered, but encouraged.

Clearly, a part of informed self-care is knowing one’s own limits. Therefore guidelines are included not only for what to do, but for when to seek help. The book points out those cases when it is important to see or get advice from a health worker or doctor. But because doctors or health workers are not always nearby, the book also suggests what to do in the meantime-even for very serious problems.

This book has been written in fairly basic English, so that persons without much formal education (or whose first language is not English) can understand it. The language used is simple but, I hope, not childish. A few more difficult words have been used where they are appropriate or fit well. Usually they are used in ways that their meanings can be easily guessed. This way, those who read this book have a chance to increase their language skills as well as their medical skills.

Important words the reader may not understand are explained in a word list or vocabulary at the end of the book. The first time a word listed in the vocabulary is mentioned in a chapter it is usually written in italics.

Where There Is No Doctor was first written in Spanish for farm people in the mountains of Mexico where, 27 years ago, the author helped form a health care network now run by the villagers themselves. Where There Is No Doctor has been translated into more than 50 languages and is used b y village health workers in over 100 countries.

Reviews

• Where There Is No Doctor: a Manual for All Reasons by Barbara Bamberger Scott (2012)

  Frank, practical, logical. But let’s make one thing clear: Werner’s book, and the assiduous updates by his collaborators and later by experts designated by Hesperian, was not meant to replace adequate, professional medical care. It was designed exactly as it said: for the times and places when no such care is available. In Rio Limpio, for example, the “clinic” was a cinderblock building with no windows and a padlock on the metal door, obviously meant to keep people out, not invite them in. Supposedly, a nurse visited once a month. But sometimes she didn’t. I never saw that door open in the year I lived in the village. That’s WTIND territory. And it’s far from rare in the developing world.

• Book review: Where There Is No Doctor by Elizabeth Babu, MD, and Dan Eisenberg, BS. JAMA ,March 3, 2010—Vol 303, No. 9. pp 885-885.

 

 

Links

• English:

  • PDF (2015)
  • Buy at Amazon ($24.26)
  • Buy at Hesperian ($26.95)

• En Español: Donde No Hay Doctor

How Where There Is No Doctor Came About

adapted from Reports from the Sierra Madre

In the early years of the villager-run health program, I gradually drafted – with the assistance of everyone from traditional healers to medical doctors – a handbook for villagers who live far from medical centers, titled Donde No Hay Doctor (Where There Is No Doctor). My intention was to provide basic health-promoting information to isolated families who, for reasons of distance and poverty, had little chance of reaching a medical clinic or seeing a doctor. The handbook covers everything from common ailments and injuries to life-threatening illnesses.

Because many campesinos and traditional healers for whom the book was written were, at best, barely literate, I tried to present the information as clearly and simply as possible. I wrote it in the local language—countryside Spanish with an admixture of words from Cáhita (an Uto-Aztecan language related to Nahuatl), the original indigenous language of the area. I illustrated the text with hundreds of simple, explanatory line drawings integrated into the text.

Our health work in Sierra Madre gradually grew into a local villager-run health program, named Piaxtla after the main river in the area. When writing Donde, I never dreamed it would ever be used outside Piaxtla’s modest area of coverage. Produced on a shoestring, the book was formatted and assembled by a group of volunteers, again mostly friends from my teaching days in California. In 1972, a thousand copies were printed. Printing was financed through an anonymous $5000 donation. The donor, a large pharmaceutical company, provided these funds on the condition that we not reveal the source – since their lawyer worried that liability claims might be filed against this ‘unconventional’ backwoods medical guide.

Although there was no formal promotion whatever of the handbook, somehow word got around, first in México, then throughout Latin America, and then further afield. As demand grew, we arranged for wider circulation through a publishing house in Mexico City, Editorial Pax México, run by a socially conscious family of Quakers (The Society of Friends).

Pax agreed not only to make the handbook available at surprisingly low cost, but also to give Project Piaxtla and other non-profit community health programs a large discount. I insisted that the publisher, instead of using the standard prohibitive copyright notice on the title page, include an ‘open copyright’ statement inviting anyone to copy, reproduce or adapt any or all of the book, including illustrations, without permission or cost, providing this be done on a non-profit basis.

Sales quickly took off, and soon the book was widely distributed throughout Latin America. For years Pax México sold more copies of Donde than the Bible.

One day I got a letter from Dr David Morley, a world-renowned pediatrician at the Institute of Child Health in London, and author of the classic book Pediatric Priorities in Developing Countries. Dr Morley had come across a copy of Donde No Hay Doctor and was delighted by the book’s simple yet comprehensive presentation, and its accessibility to people unserved by doctors. Later, in the British medical journal, Lancet, he described the handbook as “the most important medical publication in the last ten years”.

David Morley foresaw the potential of the book in under-served populations, and insisted it be translated into English for much wider distribution – a project that I and my friends happily took on. He, along with other concerned doctors in a wide range of specialties, volunteered advice and information to make the manual more universally appropriate.

The first English edition of Where There Is No Doctor came out in 1977. It was published by the Hesperian Foundation, a small non-governmental organisation (NGO) I directed at that time in California. But within less than a year we were approached by Macmillan Press, a major British publisher with worldwide distribution. At first they baulked at our insistence that it be printed with a ‘free to copy or adapt’ policy printed on the title page. But they were so eager to co-publish the book that after nearly a year of resistance they finally agreed. In addition, Macmillan gave a major discount for a bulk purchase to Teaching Aids at Low Cost (TALC). Set up by Dr David Morley, TALC is a distributor of essential health-related publications for the developing world. It is almost unheard of for a big international publisher to agree to an open copyright policy. But Macmillan guessed correctly that the book would become a worldwide best seller. And it has remained one of their top sellers after nearly 40 years.

 

When Where There Is No Doctor first came out, it was lampooned by the medical establishment. Virtually all of the international institutions promoting community healthcare, including PAHO (Pan-American Health Association), WHO (World Health Association), UNICEF, and CMC (Christian Medical Commission), were scathingly critical of the book. They said it was way too long, and that people with little schooling would have no interest in it. They asserted that “a little knowledge is a dangerous thing”, and that entrusting “ignorant” villagers (or even community health workers) with medical information usually reserved for doctors was hazardous.

But as more and more grassroots programs began to use the book successfully with community health workers and medical auxiliaries, little by little these global institutions began to change their tune. Eventually UNICEF sponsored the translation of Where There Is No Doctor into a dozen or so languages. And WHO lauded the book as the most widely used Primary Health Care handbook in the world. Now, Where There Is No Doctor has been translated into more than 100 languages, with more than five million copies in print.

About the Contributions of Dr. Carlos Miller and Dr. Val Price

adapted from an unpublished manuscript

As I was drafting the different chapters, I had generous assistance from specialists in every pertinent field of medicine – from pediatrics to obstetrics to ophthalmology to dermatology – who went over the manuscript and made numerous suggestions. The biggest challenge was not deciding what to include in the book, but what to leave out. Each specialist wanted a much larger section in his or her specialty than space allowed – or than semi-literate users were likely to wade through – so we had to make some difficult decisions. With every item of content, we had to ask ourselves how essential it was to saving lives, protecting health, or improving the wellbeing of the intended users.

While most of these collaborating doctors were based in the USA, several were in Mexico. One who became devoted to the project – and whose input was most valuable – was a graduating medical student, Carlos Soto Miller, who did his year of national service in the village of Ajoya and helped out in our villager-run health post. His input was especially useful because he worked alongside us in the environment for which the book was written. Also he had a respect for traditional medicine, and helped us to integrate some of the most efficacious folk remedies into the book.

But the doctor who was the biggest help of all was Dr Valery (Val) Price, the pediatrician, originally Canadian but then living near Palo Alto, California. […] When I was drafting the handbook, for months on end Dr Price provided his help, often working deep into the night with me, poring over the manuscript.

His assistance was especially valuable because, during his visits to the Sierra Madre, he had gained great respect for the campesinos’ observational skills and healing abilities. He realized that villagers with limited formal education could do far more in terms of resolving their health needs than most medical professionals dreamed was possible. It was his respect for underprivileged people’s native intelligence and problem-solving abilities – and his willingness to learn from them as well as teach them – that made his contribution so invaluable.

Sometimes Dr Price would spend hours researching the medical details and the most appropriate form of treatment for a particular problem. We both realized that ‘most appropriate’ did not always mean the most up-to-date or highly recommended protocol in the medical literature – but rather that which was most likely to work for impoverished people in remote villages with limited resources – and no doctor. When recommending a specific medicine for a particular problem, we had to think not just which medicine was likely to work fastest and best, but weigh that against cost, availability, durability without refrigeration, ease of administration (pills rather than injections wherever possible), and relative safety, including side-effects or dangers if misused.

About Myra ‘Polly’ Polinger’s Contribution

adapted from an unpublished manuscript

Among the many who helped bring Donde No Hay Doctor to completion, the person who threw herself into the effort with more love and devotion than anyone else was my friend Myra Polinger (Polly). I first met Polly in 1961. She was the mother of two children at Peninsula School, where I was teaching the summer natural science program. We’ve remained close friends ever since. During the early years of the health program I’d initiated in Mexico, when I came back to the States I’d stay in Polly’s home in Menlo Park, California – where she cared for me like a homecoming son. I’d written the original manuscript of Where There Is No Doctor by hand and drawn most of the illustrations right on the handwritten pages. It was Polly who eventually typed them, first in a draft for further editing, and then the final, unblemished camera-ready copy for plate-making and printing. Considering the text was in Spanish – which Polly didn’t know – the accuracy of her typing was astounding. […]

When the manuscript was complete, a Spanish literature professor at Stanford University volunteered to proofread it with the help of students who were native Spanish speakers. Then Polly took on the yeoman’s task of typing and formatting the final camera-ready pages, called ‘art boards’. We were still in the dark ages in terms of computers or digital printing, so the copy had to be letter perfect and spotlessly clean. The text needed to be formatted to leave spaces for all the differently sized and oddly shaped pictures that subsequently had to be integrated into the text. Any typo or miscalculation of space for pictures meant that the entire page had to be retyped. For Polly the challenge was especially daunting because she knew no Spanish and therefore had to copy the whole manuscript letter by letter. Fortunately she was a highly skilled touch-typist who had previously worked as a secretary in a law office. She did a masterful job.

Once the pages were flawlessly typed, we had the laborious task of pasting in all the hundreds of pictures. Fortunately Polly had a friend who worked at a press and had all the necessary paste-up skills. Every evening after work he came to Polly’s house. For weeks, often until after midnight, he, Polly, and I would sit around her kitchen table gluing down each drawing or photo with rubber cement and then sticking narrow strips of non-reflective white tape around all the borders of the pictures, to prevent shadows when the art boards were photographed to make the plates for printing. By doing all this work ourselves, rather than have the printer typeset and format the pages, we saved money. Equally important, we had much more control over the layout and design.

The integration of the drawings into the text needed to be meticulously done. It was very demanding work. Polly, by nature a perfectionist, worked herself to a frazzle, drank gallons of coffee, and took extra-strength aspirin – in hopes it would give her extra strength. She complained I’d turned her into my personal slave and her house into a sweatshop. But then she’d laugh and say she loved it. In those days Polly’s daughter, Nina, was going through a withering physical and emotional crisis, and Polly welcomed the chance to focus on something that took her away from her personal life and let her do something that ‘made sense’.