Exploring the Americas for Community Supportive and Community Oppressive CBR Programs

During the Spring and Summer of 1976, three former Project Piaxtla volunteers—Bill Bower, Lynne Coen, George Kent— and I traveled through Central America and northern South America to visit and learn from community-based rural health programs. For the first part of our travels we were accompanied by Martín Reyes, coordinator of Project Piaxtla and chief village medic of the Ajoya clinic. The objectives of our study-expedition were to encourage a productive dialog among the different programs, as well as to try to draw together many respective experiences, insights, methods, and problems into a sort of field guide for health planners, so we can all learn from one another’s experience.

We were able to visit nearly 40 rural health programs, both government and private in nine countries.

The study trip proved exciting and provocative. By splitting at times into smaller groups, we were able to visit nearly 40 rural health programs, both government and private in nine countries (México, Guatemala, Honduras, El Salvadór, Nicaragua, Costa Rica, Ecuadór, Colombia, and Venezuela). We were inspired by much of what we saw in some programs, and troubled by what we saw in others. While virtually all the programs reportedly espouse a high degree of community participation with “primary decision-making by the villagers themselves,” in certain programs there was considerable disparity between the stated and apparent objectives. While some of the health programs genuinely regarded people as a resource to control disease, it became equally clear that others were using disease as a resource to control people. We came to look at programs and activities as falling somewhere along a continuum between two diametrically opposing poles: community supportive and community oppressive.

Community supportive programs or functions are those which favorably influence the long-range welfare of the community, that help it stand on its own feet, that genuinely encourage responsibility, initiative, decision making and self-reliance at the community level, that build upon human dignity.

Community oppressive programs, or functions, are those which, while invariably giving lip service to the above aspects of community input, are fundamentally authoritarian, paternalistic, or are structured and carried out in such a way that they actually encourag greater dependency, servility and unquestioning acceptance of outside regulations and decisions; those which, in the long run, are crippling to the dynamics of the community.

It is disturbing that, with a few exceptions, programs which in general we found to be genuinely community supportive tended to be small, private, or at least non-governmental programs, usually operating on a shoestring and with a more or less sub rosa status.

As for the large regional or national programs——for all their input from the big foreign foundations and/or international health or development agencies, for all their glossy brochures depicting community participation——we found that when it came down to the nitty-gritty of what was going on in the field, many of these king-size programs actually had a minimum of effective community involvement and a maximum of handouts, paternalism, and authoritarian, initiative-destroying regulations or “norms.”

A lot of game playing goes on under the name of community involvement and community development*.*

There are many factors which contribute to the distortion of a program which is community-supportive in theory into one which is community-oppressive in fact. When we asked the pioneers of people-oriented health programs in Latin America what they saw as the major obstacles to bringing about effective community-based health care, the most common replies were “doctors” and “politics”.

A lot of game playing goes on under the name of community involvement and community development. National projects for community involvement and self-help are “in” when it comes to the leviathan funding from powerful international agencies and foundations. However, in poorer countries where 10 per cent of the people possess 90 per cent of the land and wealth (much of it foreign owned or controlled), where medical professionals earn 30 to 40 times the income of the average food producer, and where multinational drug industries make hidden profits of up to 6000%, it is questionable whether the socio-political powers-that-be can afford to encourage or even tolerate health or development activities which are community supportive in the fullest sense.

Bill Bower and I plan to spend the next several months putting into useful form the results of our visits to various rural health projects in Latin America. We are seeking (but so far have had discouragingly little success in securing) foundation support to do this. In addition to the previously mentioned source book of ideas and methods for program planners, supervisors, and instructors, we also plan to produce a perhaps more controversial volume, which will deal with the political, philosophical, and humanistic issues underlying the different approaches to health care in Latin America.

This latter volume will be an expansion of a paper, entitled Health Care and Human Dignity, which I recently presented at a symposium on Appropriate Health Technology in England. If you are interested in obtaining a copy of this paper, please fill out and send to the Hesperian Foundation the application at the end of this announcement, together with a donation of at least $2.00 to help cover xeroxing and postage. More substantial donations are sorely needed for the further development of this and other materials, and will of course be deeply appreciated.

Updates on Donde No Hay Doctor—Revision and Translations

The Spanish edition of Donde No Hay Doctor (my villagers' medical and health care handbook) has a number of shortcomings of which I am becoming increasingly aware. A revision is needed and will be undertaken as soon as time and resources are available. Nevertheless, the book has been enthusiastically received throughout Latin America, especially by villagers themselves. In Costa Rica it is distributed to all the rural nurse-auxiliaries working for the Health Ministry, and in Colombia it has been translated into Guajivo, the main Indian language of the Llanos.

An experimental edition of the modified English version, Where There Is No Doctor, is almost ready, and should appear in the Spring of 1977. Hopefully, it will fill a need in Anglophonic parts of Africa and Asia, as well as provide the prototype for translation into other languages; interest has been expressed for Portuguese, French, Hindi, Urdu, Swahili, and Indonesian.

The Future of Hesperian: Manuals Promoting Informed, Mutual Self-Care

My recent trip to England confirmed our observation that throughout Latin America and the developing world, there is a conspicuous lack, as well as great need, for simple (but not childish) self-help manuals in fields relating directly or indirectly to health. Now that my frequent absence from the ongoing program in México has become more necessary than my presence, I feel that one of the most important roles I can fill in rural health care is to participate in the creation of this sort of self-help manual.

Already, with potential collaborators in Guatemala, Honduras, Costa Rica, Colombia and England, we have begun a dialog for the preparation of self-help manuals in the fields of village dentistry, veterinary care and animal husbandry, agricultural extension appropriate village architecture, midwifery and home rehabilitation/physiotherapy. The proposed manuals will be geared to the assumption that people with little formal education have the native intelligence and potential will to meet most of their basic needs for and themselves. They will do so if given half a chance, and if provided clear precise information in the idiom they best understand.

Now that my absence from the Piaxtla Project has become more necessary than my presence, I feel that one of the most important roles I can fill in rural health care is to create of self-help manuals.

The development of these self-help manuals will be a practical and tangible step in our growing campaign for informed, mutual self care as a viable alternative to the present dehumanizing onslaught of institutionalized health care delivery. To be most effective, primary health care should not be delivered, but encouraged. It should largely be a question of education, and fostering informed personal concern. Yet as governments of the world have increasingly come to accept the doctrine of the World Health Organization, that access to health care should be considered a basic human right, a mass, politically-loaded movement has sprung up to try to deliver pre-packaged stereotyped health care services to all. The result has been to expropriate both the responsibility and practicability of health care from the people themselves and to make them increasingly dependent on the central power structure.

I suppose one must agree that access to health care should be considered a basic human right. Yet when health care is turned into a formula or system imposed upon the oppressed by outside benefactor-oppressors, this “human right” can become a humiliating and disabling wrong. I would prefer to be a spokesman for what I am coming to see as the most fundamental, and certainly the most easily alienable, of human rights: the right of the, people – as individuals, as families and as communities – to stand on their own feet, to make their own decisions, and to care for themselves.

Nowhere has this basic right been so systematically and purposefully denied than in the sectors which bear those political euphemisms——Health and Welfare. The implications of this have been discussed to some extent in the paper, Health Care and Human Dignity, and I hope to explore them more fully in the expanded version of this paper as well as in future newsletters.

End Matter

This issue was created by:

David Werner — Writing, Photos, and Illustrations