Public Health, Poverty and Empowerment
-- A Challenge
Convocation Address, John Hopkins
School of Public Health, l985
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
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
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
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
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,
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
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
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,
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
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
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
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.