LIBERATION FROM WHAT?: A Critical Reflection on the People’s Health Assembly, 2000

HIGH POINTS OF “PHA2000”

By many measures the PHA event was a roaring success. Nearly 1,500 people from 93 countries gathered at Gonashasthaya Kendra (GK), in Bangladesh, to form a worldwide coalition of organizations and movements committed to work towards a healthier, more equitable, more sustainable world. The venue was well chosen. GK is one of the most revolutionary and inspiring community-based health programs in the world. The physical and social ambiance was fabulous! No five-star hotel for this huge forum; Instead, a spacious auditorium was built behind the tranquil lakes and fields where the GK workers grow food for the community program. Building the auditorium was no easy task. Due to heavy rains and tardy funding, two days before the event the vast structure still had no roof. But miraculously it was completed at daybreak the morning the Assembly began—thanks to the valiant efforts day and night of over 1,000 workers!

 

But how did the GK team manage to feed 1,500 people in this rural setting? Rather than busing folks to restaurants or trucking in costly catered cuisine, they built a covey of small bamboo sheds and invited women from neighboring villages to come prepare traditional food. The chance to perch out-of-doors on handcrafted bamboo stools, eating chapatis and dhal while trying to communicate with the gracious village women, was one of the high points of the Assembly. It somehow symbolized what we were collectively seeking to achieve: an innovative yet ancient way of transcending the commercial, hierarchical barriers that separate people from one another and their dreams. It brought us down-to-earth through the common understanding of each and everyone’s most fundamental right, above all else: to have enough to eat.

It was during these communal meals, with six or eight of us activists and progressives from different parts of the world clustered around a table comparing our insights, that some of the most meaningful and potentially transformative interactions of the PHA too place. After attending countless international conferences and forums over many years, this was a marvelous opportunity to chew the fat with so many old friends and fellow warriors for social justice.

 

The energy and enthusiasm generated by the PHA was enormous! For all the diversity, the people present had in common a passioned commitment to change. Many were spokes persons for disadvantaged groups valiantly struggling to improve their situations—or at least to survive with dignity—in circumstances that in recent years have become more and more difficult and oppressive. Needless to say, an enormous amount of pain, anger, and frustration was vented. But most important, a great sense of international solidarity emerged.

“TO GIVE THE VOICELESS A VOICE” was a foremost goal of the People’s Health Assembly. And indeed, the PHA had strong representation from a wide spectrum of marginalized and underprivileged groups, many of whom had never before had a chance to speak at a local council, much less at an international forum. Speakers from all corners of the earth represented everyone from community health workers to traditional birth attendants, from mothers’ clubs to a collective of unemployed alcoholics (from Scotland), from tribals to racial minorities, from migrant workers to refugees, and from commercial sex workers to activists with AIDS. A wide spectrum of NGOs ranged from grass-roots movements to the Rockefeller Foundation.

Unfortunately, current leaders of the World Health Organization and UNICEF were conspicuous by their absence. However, a big boost to the legitimacy of the PHA and its depth of discussion was provided by Halfdan Mahler (former General Director of WHO). Mahler was the guru behind the Alma Ata Declaration in 1978, which set the worldwide goal of “Health for All”—still our dream!

The PHA was a marvelous forum for sharing experiences and exchanging ideas. Events were enlivened by role plays, music, dancing, and poster sessions. Dramatic “testimonials” of personal hardships—many of which brought tears to the eyes—portrayed the setbacks that people were suffering due to social injustice, unfair laws, and globalization. To give more people a chance to speak out, literally hundreds of relatively small concurrent sessions were held, ranging from women’s rights to genetic engineering and everything else under the sun.

One of the major achievements of the People’s Health Assembly was the debate and collective approval of a “People’s Charter for Health.” The Charter declares social and legislative changes that are needed to put the basic needs of people before the profit interests of giant corporations. It calls for policies which promote the equity and balance essential to creating a healthy and sustainable world. It is hoped the Charter will help form the agenda for a broad-based people’s movement that can pressure those in power—governments, the United Nations, WHO, and the international financial institutions (World Bank, IMF, and World Trade

Organization)—to work toward a paradigm of people-centered economic and social development that is conducive to Health for All.

The Importance of the pre-Assembly Activities—Especially in India

In speaking of achievements of the People’s Health Assembly, it is important to emphasize the many local and national pre-Assembly activities that prepared the way for the international event in Bangladesh. In many parts of the world, activists and NGOs held seminars, collected testimonials, gathered information, and prepared materials to involve and enlighten people about the underlying structural causes of ill health, their roots in the top-heavy global economy, and the need for a massive uprising to demand healthier, fairer, more sustainable alternatives.

Last September David Werner had the fortune to participate in a “National Forum for Health of the People” in Ecuador. (This is described in the Newsletter from the Sierra Madre #43). Similar forums took place in Central America, Europe, Palestine, South Africa, the Philippines, and Bangladesh.

But the largest, most incredible, pre-Assembly activity took place in India. In the weeks before the PHA event in Bangladesh, over a thousand Indian NGOs took part in a huge National People’s Health Assembly in Calcutta. To mobilize mass participation and inform the citizenry of the issues involved, the organizers published a series of provocative, comic book-like pamphlets. Written in the common languages of the people, these colorfully portrayed the root causes of poor health and their links to the global economy.

To transport the thousands of participants to Calcutta, facilitators organized three “Health Trains,” which traveled across the country from different corners of India. At stops along the way, they held demonstrations, performed skits, and passed out flyers. In spite of all the careful planning, however, certain difficulties arose. Although carriages on the trains had been reserved weeks in advance, when participants gathered to board one of the trains, their reserved carriages were already full of passengers. “Too

bad!” said the Station Master. “No room left for your group!” As the train began to pull out of the station without them, the activists lay down on the tracks in Gandhian-style resistance, preventing the train from departing. They refused to budge until the officials added more carriages and the Health Assembly activists could board!

The National People’s Health Assembly in Calcutta was, as it turned out, much bigger than the international PHA event in Bangladesh. Over 10,000 people took part in the Calcutta event, and the “People’s Health March” through the city had over 20,000 people! In terms of widely communicating the core issues at stake—including how the global economy afflicts the health of people and the environment—in some ways India’s pre-Assembly event surpassed the international Assembly in Bangladesh.

SHORTCOMINGS

Perhaps the greatest strengths of the People’s Health Assembly were 1) building a sense of international solidarity, and 2) enabling process of catharsis. People from disadvantaged groups around the globe had a unique chance to air their grievances…and did so with eloquence and passion.

But lamentation alone does not lead to liberation. Critical analysis, grass-roots organizing, and carefully planned strategic action do. Or at least they have a better chance of doing so.

 

Insufficient Direction

Some of us feel that the biggest weakness of the PHA event in Bangladesh was its preordained lack of direction, in both content and facilitation. While most of us had a general sense of where we wanted to go, and an embryonic vision of the people and environment-friendly social order, there wasn’t enough strategic planning about how to get there, not enough unifying clarification of key issues nor a comprehensive analysis of causes. Each day there was a plethora of concurrent and sometimes competing sessions, full of sound and fury. But their significance was muted by lack of feedback to the plenary sessions. It was hard to get a sense of where the Assembly was going, or what actions we might take.

Their big questions were, "But where is all this leading?" and "Yes, but how do we get there?"

Increasingly during the Assembly, a number of concerned participants, as well as progressive journalists, approached the steering group with worries that the analytic process seemed spotty and disjointed. Their big questions were, “But where is all this leading?” and “Yes, but how do we get there?” While utopian goals and sweeping demands were endlessly repeated, relatively few practical suggestions were made for specific actions that individuals and organizations could take.

Too Laissez-Faire

One problem was balance. Although a set of carefully prepared background and issue papers had been written in advance of the Assembly, and although highly knowledgeable activists and even the authors of the papers were present and willing to contribute, little time was allotted in plenary sessions for analytic overview of the key issues or exploration of workable solutions.

In planning the Assembly’s agenda it had been decided—rightly or wrongly —that it was more important to give lots of time for testimonials and input from those groups and participants who rarely have a chance to speak out. Indeed, we had argued strongly for giving plenty of time to their stories, ideas, and suggestions. But, in retrospect, perhaps the pendulum swung too far in the direction of laissez-faire.

Some interpret this dilemma within the PHA process as springing from ideological differences, in which the PHA planning group was divided into two camps:

• First there were those who feel that in a forum for change everyone should be free to speak out as she or he wishes. Those who are usually silenced should be given the first chance. The process should be open-ended. Free speech is the path to liberation. They are willing to sacrifice a degree of structure and studied analysis for the sake of full and equal participation.

• The second group believes in a degree of guidance, or facilitation with a certain sense of direction. People have the right to hear the views and learn from the analysis of those who are more fully informed of the issues at hand. Thus a public forum should not simply be a “free-for-all” but rather a well-planned educational process which can help guide people to come to realistic conclusions and formulate practical plans of action.

This is a strategic debate and there will be no easy answers. In today’s world, perhaps more than ever, there can be no freedom without a strategy based upon thoughtfulness, responsibility, and collective action. However, for better or for worse, the People’s Health Assembly was programed in a way that encouraged a lot of free expression of diverse experience and views. Unfortunately, it lacked sufficient facilitated direction—and unifying analysis—to carry it forward toward a workable plan of action. Although the last day was devoted to “The Way Forward,” few people came away with a clear sense of what might be the next step that they or their groups could or should take. Speakers too often spoke in utopian generalities, such as, “We must stop the World Bank from putting corporate greed before human need,” or “governments should regulate the

health-endangering practices of the free market.“But rarely did they give any practical suggestions of how to convert these dreams into reality. There were lots of slogans and applause, but too little sense of direction.

With this critique, however, we do not mean to imply that there were no excellent speakers. Indeed, many were superlative and their presentations deepened our understanding of important issues. Missing was an integrated framework tying the main issues and presentations together, to keep the discussion moving forward rationally.

 

Not Sufficiently Multi-Sectoral

Another shortcoming of the PHA event was that it—in spite of our best intentions—was dominated by the health sector. Although we planners agreed and many speakers emphasized that “health is determined more by social, political, economic and environmental factors than by medical services or public health measures per se,” important sectors other than health were inadequately represented.

Indeed, some golden opportunities were missed. For example, Vandana Shiva—one of the world’s leading activists for environmental sustainability as it relates to ocial justice—had agreed to come to the Assembly. (She had been urged to do so by her sister, Dr. Mira Shiva, a member of the PHA steering group.) But because Vandana was not slated to speak at a plenary, she decided not to attend, rightly feeling she could make more of a contribution elsewhere.

For similar reasons the ground breaking NGO, Partners in Health, which had hoped to present its eye-opening evaluation of the World Bank’s Year 2000 World Development Report on “Attacking Poverty,” also decided not to attend the Assembly.

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Also absent among the speakers at the PHA plenaries were leaders in the field of alternative economics, such as the International Forum on Globalization, and TOES (The Other Economic Summit). This is truly unfortunate. If the People’s Health Assembly hopes to gain leverage in making the forces behind the global market more accountable to the world’s people, it is imperative that the coalition it is trying to build embrace the full spectrum of sectors and movements that relate to human and environmental health and well-being.

Too Much Rabble Rousing; Not Enough Dialectical Debate—(Shouting Down the World Bank)

An internal confrontation on the third day of the PHA threatened to bring the entire assembly to a screeching halt. Scheduled to speak was Richard Skolnik, Director of the World Bank’s Regional Division of Health, Nutrition, and Population for Southern Asia. That morning, the Indian contingent at the PHA (more than 200 strong) decided to boycott the session. Although planners of the Assembly argued that they had invited Mr. Skolnik in hopes of an enlightening debate, the Indians were adamant that the World Bank had no place at the People’s Assembly. The decision to invite the Bank, they said, had been made undemocratically by the planning committee, and it was the obligation of justice-seeking participants to protest it. The planning group suggested a middle-ground. Fifteen minutes could be allotted before Mr. Skolnik was scheduled to speak. The planners could present their reasons why he had been invited. The Indians could present their grounds for his exclusion. Then the entire audience could decide by vote. This would permit a democratic decision about the inclusion of a woefully undemocratic institution.

But the possibilities for a middle ground solution were swept aside by Zafrullah Chowdhury, the Director of Gonashasthaya Kendra, who had personally promised Mr. Skolnik that he would be given a respectful, protest-free forum to debate the Bank’s position. Consequently, when Mr. Skolnik rose to speak, the Indian contingent, spread out through the audience, stood up with jeers and placards to protest. Zafrullahjumped on the stage and shouted back. He tried to explain to the raging crowd that while the high-level summits of the World Bank fully merited demonstrative protests, and even civil disobedience, that it was uncalled for to obstruct a mutual opportunity for dialogue and debate. Even on the battlefield there is a place for a truce, or time-out, to explore the possibilities of a less bloody way forward.

The shouting match continued for about 15 minutes. Then it suddenly quieted down and the audience allowed the World Bank spokesman to speak. The point had been made.

Mr. Skolnik failed to mention how World Bank policies outside the health sector have helped to concentrate wealth in the hands of transnational corporations and to widen the gap between rich and poor

For many of us, paradoxically, this World Bank session turned out to be one of the most pivotal and educational events at the PHA. Some of us learned more from it than from any other session in the 6-day Assembly. For example, to counter the arguments of the World Bank, the people’s movements need to be much better informed and well documented in what they say. Indeed, Mr. Skolnik made many excellent points, and cited numerous actions of the Bank’s Health Division that appear strikingly similar to those advocated by the People’s Health Charter. He stressed the importance of prevention, out reach to underserved areas, women’s rights, provision of essential drugs, sustainability, and assurance that all people’s basic health needs are equitably met. He gave examples of interventions where the World Bank has encouraged governments to invest more in primary health care than in costly tertiary care for the rich. A lot of what he said sounded disturbingly progressive. In fact, if we in the audience had not known the speaker was from the World Bank, we might have erred on the side of cheering rather than booing him—which of course everyone did.

It was not so much what Mr. Skolnik said, as what he carefully omitted saying, that revealed the wolf in sheep’s clothing. While he stressed the importance of “reducing poverty” as key to approaching Health for All, he failed to mention how World Bank policies outside the health sector have helped to concentrate wealth in the hands of transnational corporations and to widen the gap between rich and poor. He skirted around the negative impact of the Bank’s “structural adjustment policies” (SAPs) which—with their demand for privatization of medical care and cutbacks in public spending—have made it harder for poor people to get the health care they need. In short, it is not what the speaker said, but what he didn’t say, that showed the Bank’s true colors.

 

After Mr. Skolnik sat down, three well known critics of the World Bank and IMF were given the floor, and each made illuminating or provocative points. The most cogent arguments exposing weaknesses and inconsistencies of the World Bank were presented by David Legge, an Australian and key player in the International People’s Health Council. It was unfortunate that much of the substance of David’s talk did not receive the same attention as the two other speakers who, though they too made some penetrating observations, tended to be more committed to oratory than substance. To their statements like, “The World Bank is an enemy of people! We must close them down!” the audience thundered jubilantly, “Down with the Bank!”

Language and Communication

What was disturbing was that while some members of the audience were very tuned to the issues, others were more into applauding or hooting than careful listening. And sometimes they missed their cue. Sometimes they would clap when they should have gasped, and booed when they should have clapped. In terms of critical awareness (which is essential in the struggle for change) we still have a way to go. In fairness, part of the problem was language. The plenary sessions were entirely in English, and then the range of accents and locution was such that even listeners whose first language was English had a hard time understanding. The Latin American contingent got so frustrated at being “left out” that at one point they threatened to boycott the Assembly and to hold their own separate meeting instead.

It would have helped had the facilitators and speakers received guidelines in advance on basic methods of effective large-group communication. (David Werner had been invited to help lead a pre-conference session on this topic, but the invitation reached him so late that he had already a previous obligation. In the end, the session never took place.)

One method used to assist communication, especially for those with difficulty in English, was to use overhead projectors to show the script of key presentations on large screens. However, no guidelines had been given as to the size of print for projection. As a result, many scripts appeared in such small print that for much of the huge audience they were impossible

to read.

FOLLOW-UP ACTION

Everyone agrees that the real success of the People’s Health Assembly will depend on action and activities the participating individuals and groups manage to undertake after the Assembly. What small but significant steps will we take that effectively contribute to building a fairer, healthier world—or at least a corner of it?

Potentially, one of the most positive outcomes of the PHA is the People’s Charter for Health. It can provide a platform on which people can organize and lobby for change. But unfortunately, within the Assembly, the recommendations for mechanisms and actions to do this have not yet been clearly worked out.

Perhaps this is as it should be. Circumstances in different countries and communities differ widely. Approaches to problem solving must be adapted accordingly.

Nevertheless, in unity lies strength. For the People’s Health Assembly to move forward toward transforming unfair and unhealthy social structures, especially at the global level, the solidarity that emerged at the PHA in Bangladesh must be sustained and reinforced. There needs to be continued active communication among participants, and a mechanism whereby groups in different parts of the world can be supportive of one another in times of crises.

 

It is critical to maintain adequate channels for information sharing. The PHA web site on the Internet is a good start. To optimize it, however, we need a team of responsible people to mantain up-to-date information and to coordinate input from the various NGOs, health movements, and activists involved. At the same time a strong effort is needed to link up and communicate with similar coalitions in other sectors, including the environmental sector and alternative (people centered) economics.

It must be remembered, however, that only 5 percent of the world population has access to computers and the internet. If the PHA is to reach and involve a broader sector of the population—including those with the least voice in the decisions that affect their health and lives— more traditional means of communication are also needed. These include newsletters, radio, videos, and street theater, as well as community health others who learn to be effective educators and agents of change.

For all this to happen—and for the movement behind the People’s Health Assembly to stay alive—all of us involved must look for ways to contribute and to encourage others to contribute, each in our own way.

It will be an uphill battle, but the struggle is worth it. In the long run, it is a struggle for the life, health, and survival of our species and our planet.

ORGANIZATIONAL LESSONS LEARNED FROM THE PEOPLE’S HEALTH ASSEMBLY (PHA2000)

To follow is a tentative list of suggestions based on lessons from the People’s Health Assembly, held in December 2000 in Bangladesh, that may be helpful in planning a follow-up event or other popular forums for change.

Keep the Event Democratic Yet on Track

• Seek a balance between guided facilitation and open-ended discussion.

• Clarify from the start (as a guided group process) the overall vision and objectives of the event. At the end of each day assess the progress made (and obstacles encountered).

• Allow time in plenary sessions for well-informed speakers/educators to provide clear but comprehensive overviews. (There needs to be A CLEAR UNIFYING ANALYTICAL FRAMEWORK, presented and discussed in a plenary, that provides a foundation and overall direction for the event as a whole.)

• Prepare in advance guidelines for facilitators that will help them keep the process democratic yet on track. (Facilitate a participatory process that keeps discussion focused and makes steady progress toward the agreed upon vision and objectives).

In Preparation for the Event

• Be sure analytic and steering committee members (and/or supporting staff) can devote enough time to adequately plan guidelines, facilitate prompt communications, and carefully review potential contributions/activities for the program agenda.

• Be sure avenues of communication, E-mail addresses, and web sites are correct and functioning as well as possible, and that all correspondence is promptly answered.

• Seek input from participants (experiences, papers, stories) which are structured in an analytic, problem-solving way that can give a pragmatic direction to the conference.

• Screen stories and testimonies ahead of time. Give people suggestions for helping their presentation contribute to the thrust of the conference: i.e. linking local hardships to global events through a carefully analyzed “chain of causes.”

• Make an effort to invite key speakers and participants from all sectors that have been agreed upon to be included in the event (health, environment, alternative economics, education, labor unions, etc.). Be sure each sector is strongly and equally represented.

 

Improve Communications

• Coach presenters to speak clearly and slowly, and to illustrate points with real-life examples and evidence.

• If overhead projections are used, make sure print is large enough to be easily read from the far corner of the room.

• Have a skilled communicator/educator give a clear, accurate summary after each session.

• Look for effective ways to share the key points and conclusions of concurrent sessions at the plenary. (Focus on those points that will carry

• the conference theme forward.)

• Check if people understand what speakers are saying (in terms of both language and content), and look for ways to share ideas more effectively.

• Make arrangements for simultaneous translation, even if it means one bilingual person whispering into the ears of others.

Keep the Process Rational and Constructive

• Encourage both speakers and participants to present fair, balanced, accurate information, and to criticize policies or institutions based on solid evidence and experience.

• Welcome thoughtful debate and discourage slogans, rhetoric, and offensive banter.

• When considering whether to invite a person from “the opposition” (e.g. World Bank), sound out participants in advance—and take their suggestions into account.

• If a speaker from “the opposition” has been invited to speak, listen to him courteously. Oppose his arguments with better arguments—not abusive language and tomatoes.

• Back up your arguments with solid evidence and hard-to-refute studies and facts.

Toward a Way Forward

• Plan for follow-up action when planning the event.

• Schedule plenty of time in the forum for discussion of “the way forward.”

• In that discussion, have facilitators who can keep input relevant and down to earth.

• Identify groups and organizations like the Third World Network that are active in specific areas. Ask them to identify, lead and coordinate the area of their expertise as identified in the People’s Health Charter.

• During the event, record if possible by tape all the plenary presentations, and the concurrent sessions.

• Have someone carefully edit this material and make the conference proceedings available in publications and on the web. Include instructive

• illustrations (verbal, pictorial) to liven it up.

After the event (follow-up and future action):

• Before the event, plan (and try to raise funding) for follow-up activities and action.

• Make sure adequate funding and personnel are available so that communications and coordination are smoothly maintained after the conference is over, and proposed activities continue and multiply.

• Make every effort to maintain full and clear communication with all participants.

• Be sure everyone (including those without E-mail) has a COMPLETE ADDRESS LIST (mailing addresses, telephone, fax, E-mail, and web site of all groups/participants.)

• Develop and maintain various avenues of communication—E-mail, web site, printed newsletters and group correspondence—to keep participants informed and involved in action plans. Keep web sites (complete with relevant LINKS) regularly updated.

• Encourage support and solidarity with all participants in the struggles of one another’s groups, especially in crisis situations.

End Matter

Board of Directors

Trude Bock

Roberto Fajardo

Emily Goldfarb

Barry Goldensohn

Bruce Hobson

Eve Malo

Myra Polinger

David Werner

Jason Weston

Efraín Zamora

International Advisory Board

Allison Akana — United States

Dwight Clark — Volunteers in Asia

Donald Laub — Interplast

David Sanders — South Africa

Mira Shiva — India

Michael Tan — Philippines

Pam Zinkin — England

María Zúniga — Nicaragua

This Issue Was Created By:

David Werner — Writing, Photos, Layout, and Most Drawings

David Sanders — Writing

Trude Bock — Editing and Production

Margaret Paulson — Editing and Production

Consuelo Perales — Editing and Production

Marianne Schlumberger — Proofreading

Emily Bock — Proofreading

Bruce Hobson — Proofreading and Editing