VI. Redefining the Balance of Power
If PSFs were empowered to fill a broader, more useful range of responsibilities at the village level, there is likelihood that child and maternal health could significantly improve. And if PSFs learned to take a discovery-based, participatory approach to help people analyze and address the underlying causes of poor health, improvements might be even greater.
It is equally important that the Health Ministry recognize and work with the TVAs (traditional birth attendants), inviting them to play a much stronger role in pre-natal and post-natal care.
But for these things to happen, a radical transformation in the health system (and the overriding power structure) will be needed. Officials will need to be more humble: less in command and more at the service of the people. Likewise the Health Ministry needs to listen more closely to the real needs of the people, and challenge the mandates of WHO that stand in the way of realistic problem-solving.
Revolution of the Conventional ‘Skills Pyramid’
Health in a country or community, and the world as a whole, is largely determined by the distribution of wealth and power. Greater equality leads to a healthier, more cohesive population.
To build a healthier, more egalitarian society, everyone needs to relate to one another as equals. In Health Care, as in other fields, the typical “pyramid of authority” needs to be turned on its side:
In the conventional health-care pyramid, the community is on the bottom, the local health promoter is just above the community, and the doctor is on top.
To gain more equality, this top-down pecking order must change. But we don’t want to turn the pyramid upside down, because we don’t want to see anyone on top of anyone else.
Instead, we need to tip the pyramid on its side. This way everyone is on the same level, as equals. The community comes first. The health promoter is at the service of the community. And the doctor is at the service of both the health promoters and the community: The doctor is ON TAP and not ON TOP.
Health Education for Change
In the chain of causes that leads to given patterns of health, it is important to consider the role of education, whether public schooling or health education in particular. “Education,” for better or for worse, is important for the health of society: The way learning is approached can influence the equality or inequality within a population. Above all, it can influence the balance of power, a fundamental determinant of health.
To build a healthy society the population must be alert to the tendency of leaders—even those they elect—to put their personal ambitions and neuroses before the common good. To build and sustain a just, egalitarian society, the common people need to be watchful and well-informed. They need be able to make their own observations and draw their own conclusions, not simply to obey orders, memorize lessons, and do as they’re told.
Such obedience training of conventional top-down schooling can be an obstacle to health. In countries where wealth and decision-making power are concentrated in the hands of an elite minority (as is the case in most so-called democracies) the school system serves as an instrument of social control. Its aim is to turn young people into complacent adults who embrace the status quo, obey authority, and fit into the social hierarchy as it exists. It aims to create obedient followers, not agents of change.
If a country in transition like Timor-Leste is to build a healthy, equitable, sustainable society free of poverty, it will need to radically transform its approach to education. Teaching will need to focus on helping young people think for themselves, analyze their common needs, and work together to improve the Well-being for All—now and into the future.
With this in mind, in the workshops I led in Timor-Leste, I placed emphasis, not just on the content of health education, but also on the methodology. We spoke of the Brazilian educator, Paulo Freire’s Pedagogy of the Oppressed. In his “awareness-raising” approach (conscientizacao) Freire helped groups of marginalized people critically reflect on their common needs and take collective action to (in Freire’s words) “change the world.” In Latin America Friere’s “education of liberation” methods have been widely adapted to grassroots health promotion—sometimes with revolutionary results.
In the Timor workshops we introduced a number of discovery based “Education for Change” activities and teaching aids developed in Mexico and elsewhere. One highly imaginative PSF, named Julio, was especially talented in making eye-catching educational materials. To teach oral hygiene he’d created a comical Moppet-like head from a coconut, with a huge mouth that opens and closes. To teach the importance of impregnated bed-nets for preventing malaria he made two miniature beds, with dolls in them, one covered with mosquito netting and the other not. Out of old rubber sandals he’d made giant mosquitoes, which viciously attacked the unprotected doll. People with Julio’s rich imagination and creativity can be a valuable resource to a health team. They make learning more fun and thereby more memorable.
While in Dili I had the good fortune to meet Dr. Aida, a courageous Timorese doctor who—despite the WHO mandate—has been working with TBAs in a remote mountainous part of the country. Her TBAs have achieved far better rates of maternal and infant survival than has nation as a whole. Last year Dr. Aida asked the Health Minister to visit her program, and he was so impressed he told her (privately) that her approach should be scaled up to cover the whole of Timor-Leste. However the Health Minister is so intimidated by WHO that he dares not take act on his wish.
In the meanwhile, Dr. Aida won approval of a grant from the Japanese Embassy of one million dollars to expand her TBA program. All she needs to finalize the donation is authorization from the Timorese MoH. But up to now the Health Minister has dragged his heels—fearful of losing WHO support.
One of my delights while in Timor was the opportunity to spend some time with Dr. Dan Murphy, a American doctor who has spent much of his life serving in places where the health needs are huge. I first met Dr. Dan in the 1980s in Delano California, when he was volunteering with the Cesar Chavez and the United Farm Workers. He also spent years in Mozambique soon after its liberation from colonial rule.
For the last 10 years Dr. Dan has worked in Timor-Leste, running a large clinic in a poor section of the capital city of Dili. The clinic has an average of 60 in-patients and with the help of volunteer doctors and students from various countries, Dr. Dan personally attends over 300 out-patients per day—showing heartfelt concern for person! One large ward is full of people with tuberculosis. Dr. Dan makes a great effort to obtain the urgently needed, costly medication for the growing numbers with multiple-resistance TB.
Dr. Dan feels strongly that for Timor-Leste to meet its enormous health needs, much stronger emphasis is needed on community-based approach into which local health promoters, traditional birth attendants, and native healers are fully integrated, with the back-up and respect of the national health system. He cooperates closely with Dr. Aida and others who are pioneering in that direction.
National Seminar in Dili
Toward the end of my stay in Timor, I spent a full day with representatives of the Ministry of Health and the Ministry of Education, in a morning seminar and afternoon workshop. I was extremely fortunate to have Dr. Dan translate my presentations into Tetun—which he wisely did not word for word, but idea for idea. In the afternoon session we involved the audience in using the “gourd baby” in discovery-based learning about dehydration and management of diarrhea. The person in charge of health education nationwide was excited about the concept of “Education for Change.” and spoke with me at lunch about introducing into the schools a discovery-based, learning-by-doing approach to Child-to-Child. He was already familiar with Child-to-Child, but not the empowering methodology used in Latin America.
At the seminar, people from the Ministry of Health also took interest in the possibility of giving a more important role to the Family Health Promoters, and of recognizing and working more closely with Traditional Birth Attendants. Unfortunately no one from WHO was present at the seminar. It is still too early to see in what direction the Health and Education systems will evolve. But at least we triggered a thought-provoking dialog. Most agreed that a lot of rethinking and innovative changes are needed.