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.
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
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
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
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
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
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
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
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
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
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
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.
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
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
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
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
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.