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People's struggle for health and liberation in Latin America: a historical perspective

David Werner

Design: El Gato

Print:Arte y Diseño

October 2013/ Cuenca - Ecuador

PEOPLE'S STRUGGLEFOR HEALTHAND

LIBERATION INLATIN AMERICA:A HISTORICALPERSPECTIVE

David Werner

Prepared for the"Encuentro Pluricultural

para la Salud y Bien Vivir"(Multicultural Encounter

for Health and Living Well)at the first international

assembly ofThe People's Health

Movement--Latin AmericaCuenca, Ecuador, October

7-11, 2013

presentación

“Hay hombres queluchan un día y

son buenos. Hayotros que luchan

un año y sonmejores. Hay

quienes luchanmuchos años, y

son muy buenos.pero hay los que

luchan toda lavida, esos son losimprescindibles”.

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Bertolt Brecht 1898-1956.

(Dramaturgo y poeta alemán)

Un espacio para hablar de la lucha y los lu-

chadores por la salud, es un tiempo propicio

para mencionar el mayúsculo rol que ha ju-

gado David Werner. Su obra, más allá de

las fundamentales producciones “Donde no

hay Doctor”, “El Niño Campesino Desha-

bilitado” o “Aprendiendo a Promover Salud”

y muchas otras más, ha sido y es un verda-

dero camino de vida. Un camino, en cuyo

luminoso trajinar han ido generando leccio-

nes y herramientas de enorme significado

para la defensa y la construcción colectiva

de un quehacer de salud desde la perspectiva

de los más excluidos, plena de dignidad y

valientemente contrahegemónica.

Sus reflexiones y metodologías alentaron a

lo largo de no menos las cuatro últimas dé-

cadas un accionar de salud comunitaria

marcada por la presencia fraterna y solidaria

de las y los promotores de salud, mujeres y

hombres nombrados por sus comunidades

para capacitarse y actuar con total legitimi-

dad enfrentado por igual al dolor de la en-

fermedad como al calor y color de la orga-

nización comunitaria.

Y es que este movimiento sanitarista popu-

lar se ha constituido en quizás la respuesta

más sólida que desde la una orilla comuni-

taria tuvo la invocación de Alma Ata (1978):

poner en marcha una apuesta que debía

llegar a proveer Salud para Todos. Hoy, 35

años después de ese llamado, seguimos es-

perando que “la otra orilla”, El Estado, con-

crete aquello a lo que se comprometió.

En este tiempo en que la “oficialidad” habla

de la necesidad de impulsar una APS “re-

novada”, y en el que nosotros reconocemos

que la APS integral no ha perdido vigencia,

se hace más necesaria aún esa luz que David

“Camino” Werner es capaz de encender

para iluminar el sendero por el que debere-

mos transitar este diario construir colectivo

aprendizajes y, desde luego, en el diario

combate por una vida digna, por una salud

para todas y todos.

Leer “La Lucha del Pueblo para la Salud y

la Liberación en América Latina: Una Pers-

pectiva Histórica” escrito a propósito de la

I Asamblea del Movimiento para la Salud

de los Pueblos – Latinoamérica, es sin lugar

a dudas una motivación especial, un lla-

mado a no claudicar, a vencer el miedo que

muchos de los gobiernos llamados progre-

sistas han impulsado como estrategia para

controlarnos, una invocación a mantener-

nos en la trinchera, un sacudón para que

recordemos con que al final del túnel, siem-

pre está la luz.

Gracias David, por ser testimonio vivo de

esta lucha; por recordarnos, que la roja ban-

dera de la salud y la dignidad, sigue y seguirá

flameando por lo alto, por ser ejemplo, por

ser camino.

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Jorge ParraMASTER EN SALUD FAMILIAR Y COMUNITARIA

PROFESOR PRINCIPAL DE LA FACULTAD DE CIENCIAS MÉDICAS

UNIVERSIDAD DE CUENCA

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ContentsI.

Introduction

II. Local and

national origins

III. the growth of solidarity

IV.

Health education for Change

V. Conclusion:

Where do we go from here?

REFERENCES

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I. IntroduCtIon

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A.THE STRUGGLE FOR HEALTH IS A STRUGGLE FOR SOCIAL JUSTICE

In our ongoing struggle for the Health and Rights of All, now in the21st Century, what can we learn from the hey-day of the CommunityBased Primary Health Care in Latin America during the last half of the20th Century?

I would suggest we can learn a lot ... including things that can helpground us in our current strategies of organized action for change. Asan aging activist from those challenging times, I would like to sharewith you some stories and lessons about the role that village healthpromoters and their grassroots networks played in the pursuit of healthand social justice in those days.

The period from the 1960s into the 1990s was an exciting if difficulttime, one of valiant popular action for equal rights and the commongood. These grassroots actions in many countries were countered bythe ruling classes with brutal repression including torture, disappearan-ces, and other violations of human rights and international law. But forall the suffering and setbacks, this was a time when some very positive,deep-seated changes took place. A number of heavy-handed dicta-torships were ousted, in spite of -- and in part because of -- their overtor covert support from the United States. In many ways, the strugglesfrom the '60s into the '90s laid the foundation for the more recent,dramatic shifts toward representative government and "Power by thePeople" that have been emerging in the 21st Century. Indeed thisnew millennium has promise of becoming the "post-neocolonial era"where marginalized peoples collectively stand up to both national andforeign potentates, and cry out, "Ya basta!" (Enough is enough!)

What we all need to remember and learn from is the key role thatCommunity Based Health Care played -- and can still play -- in this li-berating, bottom-up Struggle for Health for All. The People's HealthMovement in Latin America, as an outgrowth of this popular struggleof the previous century, can indeed be informed and inspired by itsearly history.

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B.THE POLITICIZATION OF PRIMARY HEALTH CARE IN LATIN AMERICA

Beginning in the late 1950s, in various parts of Latin America, small non-government health programs began to crop up in the poorest, most un-derserved rural areas and urban slums. It was a time when a large percen-tage of the population lived in extreme poverty, with little or no publicsupport. The political system was largely "neocolonial," in so far as the fo-reign powers that had colonized and dominated the indigenous peoplesof the Americas had been replaced by internal power structures that wereequally oppressive, though still beholden to their northern masters. Someof these countries were clearly dictatorships. Others had the trappings ofdemocracy, but the huge gap in privilege and power between the "haves"(los de arriba) and "have-nots" (los de abajo) left the poor largely voicelessand powerless. This downtrodden majority lived in abject poverty. Hungerwas common and the classic diseases of under-nutrition and poor sanitationtook a huge tool. Child and maternal mortality was distressingly high.Formal health services were out of reach of the poor because of distanceand cost. And ironically, professional medical care -- for those folks whocould get it -- was another big cause of sickness and death. Its high priceincreased hunger and lowered resistance to disease. Even today, in manycountries, the outrageously high cost of doctors and medicine is still a le-ading cause that drives low-income, working families into absolute desti-tution and total dependence.

This combination of social injustice, poverty-related ills, and minimal publicservices at this time led to the "spontaneous generation" of numeroussmall, non-government community health programs, which sprung up inthe remotest villages and most destitute barrios throughout the region.Many of these projects were started by concerned outsiders -- priests,nuns, doctors, nurses, social workers -- committed to serving the poor.

Of those who started these small grassroots projects, many were sociallyidealistic but politically naive -- at least initially. They had little understandingof the cruel-pecking order and systemic injustice that kept the poor campe-sinos voiceless, disempowered, and economically enslaved. On the contrary,these well-meaning outsiders (and I was one of them) tended to see thedevastating health problems in biomedical terms, to be corrected primarilywith biomedical treatment. But through working closely with the people,we gradually became aware of the underlying social determinants of health.

In these marginalized and underservedand largely indigenous communities, thebacklog of needs was vast. The small ma-keshift clinics were soon swamped aspeople poured in from farther and fartheraway. Short of staff, the programs beganto train local people -- including traditionalhealers and birth attendants -- as front-line health workers or "promotores desalud." Because these promotores wereselected by and served their own com-munities, most were very dedicated. Theytended to work for the people, not themoney.

As the community-based, primary careprograms evolved and became more par-ticipatory, the promotores and villagersbegan to discuss and analyze the underl-ying causes of the health-related pro-blems. Then they began to organize toovercome their common problems, at le-ast at the local level. Out of these collec-tive efforts grew informal organizations:of mothers, landless farmers, day laborers,share-croppers, even street children andyouth, all seeking a louder voice in thedecisions that affected their health andtheir lives. In this way, many informal com-munity-based programs evolved from afocus on curative care, to preventive me-asures, and finally to socio-political action.

As such community initiatives began tomobilize people to address the root cau-ses of ill health, often they were seen asthreats by the local power structure: lan-dlords, public authorities, loan sharks, me-dical professionals, and others whoseroutine exploitation of the poor contribu-ted to hunger and poor health. As a re-sult, many of the non-government pro-grams that were first welcomed asinoffensive charities were eventually blac-

klisted by the local authorities and in timeby national governments -- especiallythose that were most oppressive and dis-tant from the poor. The last thing theywanted to see was peasant communitiesorganizing to defend their health and theirrights. Increasingly harsh rules and obs-tacles were imposed for such grassrootsinitiatives, and in some countries healthworkers or participating midwives werearrested -- or worse.

As a result, in countries where organizedopposition was on the rise, many perse-cuted health workers went undergroundand joined resistance movements. Withtheir valuable health and organizationskills, some become leaders in the gro-wing liberation struggles against tyrannicalrule.

In this way, grassroots Community BasedHealth Care in Latin America came toplay a key role in the mobilization of mar-ginalized people in the struggles that con-tributed to the emerging process of ge-nuine democratization in Latin America... and beyond.

Let me give you a few examples withwhich I am more familiar.

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Work first for the people, not the money.(people are worth more...)

II. LoCaL andnatIonaLorIgIns

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A. GUATEMALA

In Guatemala, one of the earliest and most influential Community Ba-sed Health Care programs was started in the highlands of Chimalte-nango by a visionary doctor, Carroll Behrhorst, to serve marginalizedand cruelly exploited indigenous communities. This was one of thefirst programs to train local promotores de salud. As the promotoresbegan to help the villagers to analyze the underlying determinants ofhealth and take collective action to improve their situation, the militarygovernment began to view the community program and its workersas subversive. Some promotores were murdered or disappeared. Andin the years of the "scorched earth" pacification program, entire villageswere burned to the ground.

Farther north, in the highlands of Huehuetenango, a CommunityBased Program started by Maryknoll Sisters also trained local promo-tores, mainly women, whomobilized villages around he-alth-related concerns. As inChimaltenango, the programsoon fell out of grace withthe power structure. Promo-tores had to keep a low pro-file. They certainly didn't wantto get caught by the authori-ties with a copy of my book,Donde No Hay Doctor(Where There Is No Doctor).

This village healthcare hand-book -- which the programgave to all its promotores --was considered subversive,because it encouraged com-munity organization aroundneeds. When the Sisters gavethe book to their promotores,they also gave them a smallknife. That way, when thepromotores travelled from vi- the village of san Martín was burned down soon after david werner took this photo, which

appears on the cover of "helping health workers learn.

llage to village in their health work, if sol-diers stopped the bus to search passen-gers, a promotora would quickly cut openthe upholstery of her seat, and stuff thebook under it, to hide it. This preventivemeasure could be life saving. At timeshealth workers or midwives had been ki-lled simply for being caught with mybook.

During the "scorched earth" policy of Ge-neral Rios Mott, entire villagers were laidwaste by death squads for the crime oforganizing around urgent needs. Anexample is the village of San Martín,where I took the cover-photo for HelpingHealth Workers Learn, which shows apromotora teaching a group of mothers.A year later San Martín as burned to theground by the military. However, for thegovernment such brutal measure tendedto be counterproductive. Surviving villa-gers and promotores would often flee toliberated areas and join the guerillas intheir struggle for a fairer, healthier system.

B.CHILE

In Chile -- after the democratically-electedpresident of Salvador Allende was overth-rown by the US-supported military coupin 1973 -- the autocratic Pinochet juntaimplemented the neoliberal "free market"policies imposed by the "Chicago Boys."It privatized government industries andpublic services, including health. The re-sultant "Chilean Miracle" made the richricher while further impoverishing thestruggling underclass. During the dicta-torship of Pinochet, Donde No Hay Doc-tor was banned by the military. However,the publisher of the Chilean edition, Edi-torial Cuatro Vientos, took the govern-ment to court. Amazingly the court sidedwith the publisher and lifted the ban.

During this time of violent repression andvast unmet needs, a radical communityhealth program called EPES (Educación

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Popular en Salud) was born in the impo-verished sectors of Santiago and Con-cepcion. As part of its health education,EPES promoted the "concientización"(awareness-raising) and mobilization ofpeople around the root causes of poorhealth. This "empoderamiento popular"(community empowerment) played a cri-tical role in the groundswell of resistancethat eventually led to the ouster of therepressive dictator in 1988.

C.EL SALVADOR

Similarly in El Salvador in the 1970s and'80s, in impoverished areas a number ofcommunity based health programs hadarisen out of the enormous unmet ne-eds. Widespread unrest was on the rise.As measures of social control becamemore oppressive, complete with deathsquads, community health programs andworkers increasingly aligned themselveswith the Frente Farabundo Marti para laLiberación Nacional (FMLN). As else-where, the promotores played a key rolein mobilizing the groundswell of resis-tance to the Gringo-supported militarydictatorship.

D.MÉXICO

PROJIMO, the community based rehabi-litation program I just mentioned, grewout of Project Piaxtla, a villager-run health

program in Mexico's Sierra Madre Occi-dental. It is from experience with Piaxtla-- which I helped start back in 1965 --that the books Donde No Hay Doctorand Aprendiendo a Promover la Saludwere born -- and years later, Cuestio-nando la Solución: las políticas de aten-ción primaria en salud y la sobrevivenciainfantil – Questioning the Solution: ThePolitics of Primary Health Care and ChildSurvival. These three books

Like many grassroots health programs inLatin America, Piaxtla evolved through 3stages, from an initial focus on curativecare, then to preventive measures, andfinally to socio-political action. These threebooks that were born from the Piaxtlaexperience in large part correspond tothese 3 stages of the program.

In rural Mexico, the key political actionthat the promotores and the villagers ad-dressed was the misdistribution of farm-land. In violation of the Mexican Consti-tution -- which grew out of Revolution of1910 -- half a century later the best farm-land was still illegally held by latifundistas(wealthy landholders). These land-lordssharecropped small parcels to landlessfarmers at such exploitive rates that

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3 phases in the evolutionof PIAXTLA

1. Curative Care

2. Preventive measures

3. Socio-Political Action

hardship and hunger were inevitable. Asurvey we took in the mid-1960s showedthat one third of the children died before5 years, mostly from diseases related tounder-nutrition.

As the program evolved, the promotoresbrought their fellow villagers together toanalyze the root causes of poor health,and explore solutions. People began toorganize and demand their constitutionalland rights. It was long battle, with bothformal demands and direct confronta-tions. Several health workers were killedin the process. But in the end, the cam-pesinos succeeded in invading and re-claiming over 50% of the illegally largeparcels, which they divided up amongthe landless farmers.

The health results were impressive. In alittle more than a decade, child mortalitydropped to under 20% what it had been.Maternal mortality fell to less than half.And the population as a whole appearedhappier, healthier and more self-deter-mined. If an outsider were to ask a villagemother, "Is it true fewer children die nowthan a few years ago?" she would proudlyanswer, "Yes!" and would give credit to

the community health program -- if notprimarily to its medical services. Alongwith the others in her village, she wouldhave a basic understanding of the chainof causes: With the curative care, fewerchildren died. With the preventive mea-sures, still fewer children died -- but evenso, many remained too thin, and got sickand died. But when the people took uni-ted political action -- and together strug-gled to gain their constitutional land rights-- that's when the child death rate reallydropped. The reason is obvious: Whenthe people have their own land, theyhave more to eat.

E.NICARAGUA

1. NICARAGUA UNDER SOMOZA

An outstanding example of the role grass-roots community health initiatives haveplayed in the struggle for liberation fromtyrannical oppression is Nicaragua. Duringthe Somoza family dynasty -- a brutal re-gime supported by US government-cor-porate complex from 1936 to 1979 --the poor majority lived in deplorable con-ditions. Public services, including healthand education, were minimal. Violationsof human rights were rampant. Unioni-zation was suppressed and wages keptinsupportably low. Community organizingwas branded as subversive, unless initia-ted and managed by the state. Healthcare was mostly curative, doctor-hospitalbased, privatized, and like other services

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In the SierraMadre of México:

1 of every 3children were

dying before agefive, principally

from povertry andunder nutrition

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was designed to primarily benefit the tinyprivileged class. In the 1970s, 90% ofthe nation's health resources were con-sumed by just 10% of the population.One in ten infants died before age one.And more than half of Nicaragua's chil-dren were undernourished.

In Nicaragua under Somoza — as in manycountries where human rights were syste-matically violated — community healthinitiatives began to spring up. Many suchinitiatives were assisted by foreign non-government organizations or by charitablereligious groups that initially had no poli-tical motives, other than to serve the ne-edy. But the pervasive "diseases of po-verty" they encountered were so clearlythe result of a cruelly unjust social orderthat program leaders inevitably becamemore politically aware. Community healthworkers began to facilitate organized ac-tion at the local level, in an effort to ame-liorate some of the underlying man-madecauses of poor health. Thus the "promo-tores de salud" gradually became agentsof change — and were soon branded assubversives.

Due to the profound needs of los deabajo (those on the bottom), by the mid-1970s an extensive scattering of nongo-vernmental community health programsextended throughout Nicaragua, from ru-ral areas to poverty-stricken urban barrios.When I visited the country in 1977, thesegrassroots health initiatives had begun toplay a role in mobilizing people in de-fense of their well-being and rights. Andthey were encountering increasing re-pression.

In an attempt to co-opt these popular in-itiatives or make them redundant, Somo-

za's Health Ministry — with the help ofthe United States Agency for InternationalDevelopment (USAID) — launched anambitious project to train government-managed village health workers. But des-pite millions of US dollars, the top-downgovernment program received limitedcommunity support.

Meanwhile the informal network of com-munity based programs continued to ex-pand. In response, Somoza's brutal Na-tional Guard, as well as paramilitarytroops, increasingly targeted grassrootshealth workers -- along with union leadersand community organizers -- for harass-ment, detention and disappearances.

This grassroots network of community-run health initiatives played a vital role inthe broad-based awakening and mobili-zation that eventually led to the overth-row of the oppressive Somoza dynasty.In the later years of the popular uprising,the persecution of community healthworkers — as well as socially concerneddoctors, nurses, and medical students —led many to go underground and jointhe growing Sandinista resistance. As co-llective punishment, the government cutoff water, food, and other basic suppliesand services. In response, the comuni-dades de base (base communities) thatsupported the Sandinistas set up CivilDefense Committees that acted as adhoc local governments. In these "libera-ted" communities an effort was madenot only to distribute food, water, andother essential supplies, but also basichealth services. Local health volunteers,known as brigadistas de salud (healthbrigadiers) were recruited and trained.These were joined by numerous pre-exis-ting promotores de salud who had been

harassed or threatened by the NationalGuard, and hence gone underground.

In sum, it was the National Guard's co-llective punishment of liberated areas thatprovoked the Sandinistas to launch a newcommunity-based health system led bylocal activists. Historically, this approachprovided the foundation for strong po-pular participation in the remarkably ef-fective "Jornadas de Salud" (national he-alth campaigns) after Somoza wasoverthrown and the Sandinistas took overin July, 1979.

2. NICARAGUA FOLLOWING LIBERATION

In the period of transition following libe-ration, the new Sandinista government(FSLN) set about building a new, morepeople-centered Health Ministry. In wor-king towards the goal of "Health for All",on a very limited budget, it recognizedthe importance the grassroots commu-nity based health movement had playedin the revolutionary process. It startedtraining more brigadistas, using the mul-tiplier approach the FSLN had employedin the base communities. All brigadistas,after their training, were asked to sharewhat they had learned with several newrecruits. Those who proved capable tea-chers were graduated to the role of mul-tiplicadores, or hands-on trainers. Also,People's Health Councils organized theirlocal communities in Jornadas Popularesde Salud (People's Health Days). TheseJornadas were massive, country-widemobilizations against major health pro-blems, for which the entire populationwas called upon to participate. In 1980

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an estimated 30,000 volunteers carriedout a series of Jornadas to combat polioand measles (through mass immuniza-tion), dengue (by eliminating mosquito-breeding sites near homes), and variousinfectious diseases (through sanitation

projects and garbage disposal). The Jor-nadas included public education cam-paigns, and home visits to immunize chil-dren whose families had not taken themto the neighborhood centers during theHealth Days.

III. tHe groWtH ofsoLIdarIty

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A.SOLIDARITY BUILDING BETWEEN PROGRAMS

A process of networking and solidarity-building, within countriesand between countries, has been one of the most important,strategic outcomes of what became known as the CommunityBased Health Care Movement -- of which the Movimiento parala salud de los pueblos (People's Health Movement) has beenits more recent and far-reaching accomplishment.

The network grew stage by stage in an organic, bottom-up way.In the early 1960s no serious networking existed. In Latin Americathere was only a handful of small isolated nongovernment com-munity health programs. Each had arisen independently in res-ponse to overwhelming local needs. Most kept a low profile inorder to survive under oppressive regimes. And most were una-ware of each other's existence -- even when in neighboringareas. Contact between programs was minimal. But then, littleby little, some of the programs began to discover one another,and communicate.

As an example, in the first years of Project Piaxtla in western Me-xico, the villager-run health program I helped to start in the '60s,we were totally ignorant that any similar programs existed. Wewere in an isolated mountain area without electricity, and withonly mule-trails connecting the villages. When I first wrote DondeNo Hay Doctor in the early '70s, we never imagined it wouldever be used beyond the wilds of the Sierra Madre. The first edi-tion I wrote in the regional dialect of Spanish with a mix of localindigenous words. But somehow news of the handbook beganto spread to other grassroots health programs I'd never heard of,in Mexico and beyond. Little by little, different programs beganto communicate, share ideas, and eventually exchange visits.

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B.SOLIDARITY ACROSS NATIONAL LINES

One of the more inspiring aspects ofthese grassroots struggles for health andliberation in Latin America has been thepeople-to-people solidarity that grew outof it -- across national borders.

For example, in sympathy with the gue-rrilla uprising for social justice and self-determination, a spectrum of idealisticvolunteers from different countries wentto El Salvador, where they risked their li-ves in support of the popular uprising.Among the best known on the medicalfront was the North American doctor,Charlie Clements. Formerly a US soldierin the Vietnam War, Charlie had seen theevil of his country's role in that war, andrefused to participate further. Later, afterbecoming a doctor, he grew upset withthe US support of the brutal dictatorshipin El Salvador, and went there as medicand health educator with the guerilla for-ces. His experience is recorded in hisbook, Witness to War.

There are many such examples of cross-country solidarity at a personal or grass-roots level. For instance, Project PROJIMO-- a Community Based Rehabilitation inMexico that grew out of Project Piaxtla --empathized with the marginalized villa-gers struggling for liberation in Guatemala.During the late '80s and early '90s thePROJIMO team arranged secretly to bringseverely disabled guerillas from Guate-mala to their backwoods center in Sina-loa, Mexico. There they provided free re-

habilitation services and assistive devices.When rehabilitated, their disabled com-pañeros returned to Guatemala and thestruggle.

In like manner, a young Mexican doctor,Carlos Miyazaki, spent three years in Sal-vador during the '80s, volunteering in theembattled and liberated villages. Therehe trained over 300 health promoters --and provided each with a copy of DondeNo Hay Doctor (Where There Is No Doc-tor). Currently Dr. Miyazaki runs La Clinicalpara los Pobres in Sinaloa, Mexico, andis enthusiastically cooperating with thePROJIMO children's wheelchair program,with which I am currently active. (Thebooks, Disabled Village Children, and No-thing About Us Without Us grew out ofthe PROJIMO program.)

C. GRASSROOTS SHARING BETWEEN NICARAGUA ANDMEXICO

During the long struggle for liberation inNicaragua, brigadistas had used the twohandbooks that grew out of Project Piax-tla in Mexico: Donde No Hay Doctor andAprendiendo a Promover la Salud (Hel-ping Health Workers Learn). The newSandinista Health Ministry, MINSA -- wan-ting to apply the participatory methodo-logies presented in these handbooks --sent a representative from the Ministryto visit the villager-run health program inthe mountains of Mexico. Next, MINSA

invited a small group of the village healthworkers from Mexico to visit Nicaragua,to facilitate a workshop on their learning-by-doing methodology.

I had the good fortune to accompanythese promotores from Mexico on thisgroundbreaking international exchange,held in Ciudad Sandino. It was an event-ful workshop, attended by brigadistas andmultiplicadores, where we all shared ex-periences and learned from each other.To facilitate community involvement inhealth, analyze underlying determinants,and explore practical alternatives for ac-tion, we used story-telling, role plays, "Butwhy?" games, and a participatory "chainof causes," all of which will be describedin more detail later.

D.A STUDY TRIP TO LEARNABOUT OTHER PROGRAMS

Largely through the informal distributionof Donde No Hay Doctor, in the 1970sProject Piaxtla in Mexico made contactwith an assortment of community healthprograms in Latin America. In 1974 agroup of us from Piaxtla began to plan astudy trip through Mexico, Central Ame-rica, and the northern part of South Ame-rica, to visit and exchange ideas with thevarious programs. The trip took place thefollowing year. Financed on a shoestring,this informal study trip -- and the publi-cations that grew out of it -- became acatalyst for the early networking process.

In a paper I wrote, The Village HealthWorker – Lackey or Liberator? I describesome of our findings. I quote from thispaper:

On the study trip a group of my co-wor-kers and I visited nearly 40 rural healthprojects, both government and non-go-vernment, in nine Latin American coun-tries (Mexico, Guatemala, Honduras, ElSalvador, Nicaragua, Costa Rica, Vene-zuela, Colombia and Ecuador). Our ob-jective was to encourage dialogue amongthe various groups, as well as to try todraw together many respective approa-ches, methods, insights and problemsinto a sort of field guide for health plan-ners and educators, so we could all learnfrom each other's experience. We speci-fically chose to visit projects or programswhich were making significant use of local,modestly trained health workers or whichwere reportedly trying to involve peoplemore effectively in their own healthcare.

We were inspired by some of the thingswe saw, and profoundly disturbed byothers. While in some of the projects wevisited, people were in fact regarded asa resource to control disease, in otherswe had the sickening impression that di-sease was being used as a resource tocontrol people. We began to look at dif-ferent programs, and functions, in termsof where they lay along a continuum bet-ween two poles: community supportiveand community oppressive.

• Community supportive programs orfunctions are those which favorably in-fluence the long-range welfare of thecommunity, that help it stand on itsown feet, that genuinely encourage res-ponsibility, initiative, decision making

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and self-reliance at the community le-vel, that build upon human dignity.

• Community oppressive programs orfunctions are those which, while inva-riably giving lip service to the above as-pects of community input, are funda-mentally authoritarian, paternalistic orare structured and carried out in sucha way that they effectively encouragegreater dependency, servility and un-questioning acceptance of outside re-gulations and decisions; those whichin the long run are crippling to the dyna-mics of the community.

It is disturbing to note that, with certainexceptions, the programs that we foundto be more community supportive weresmall non-government efforts, usuallyoperating on a shoestring and with amore or less sub-rosa status.

As for the large regional or national pro-grams -- for all their international funding,top-ranking foreign consultants and glossybilingual brochures portraying communityparticipation -- we found that when itcame down to the nitty-gritty of what wasgoing on in the field, there was usually aminimum of effective community invol-vement and a maximum of dependency-creating handouts, paternalism and su-perimposed, initiative destroying norms.

The "Lackey or Liberator" paper also looksat the role of the community health wor-ker in the different programs we visited.Key questions we asked were:

• What skills can the village health workerperform?

• How well does he or she performthem?

• What are the limiting factors that deter-mine what he or she can do?

Again I quote:

We found that the skills that village healthworkers actually performed varied enor-mously from program to program. Insome, local health workers with minimalformal education were able to performwith remarkable competence a wide va-riety of skills embracing both curativeand preventive medicine as well as agri-cultural extension, village cooperativesand other aspects of community educationand mobilization.

In other programs--often those sponsoredby Health Departments--village workerswere permitted to do discouragingly little.Safeguarding the medical profession'smonopoly on curative medicine by usingthe standard argument that preventionis more important than cure (which itmay be to us but clearly is not to a

24

a good health promotor shares his knowledge with others

mother when her child is sick) instructorsoften taught these health workers fewermedical skills than many villagers had al-ready mastered for themselves. This so-metimes so reduced the people's respectfor their health worker that he (or usuallyshe) became less effective, even in pre-ventive measures.

In the majority of cases, we found thatexternal factors, far more than intrinsicfactors, proved to be the determinantsof what the primary health worker coulddo. [insert Outline 1 around here] Weconcluded that the great variation inrange and type of skills performed by vi-llage health workers in different programshas less to do with the personal poten-

tials, local conditions or available fundingthan it as to do with the preconceivedattitudes and biases of heath programplanners, consultants and instructors. Inspite of the often-repeated eulogiesabout "primary decision making by thecommunities themselves," seldom dothe villagers have much, if any, say inwhat their health worker is taught andtold to do.

The limitations and potentials of the vi-llage health worker--what he is permit-ted to do and, conversely, what he coulddo if permitted--can best be understoodif we look at his role in its social and po-litical context. In Latin America, as inmany other parts of the world, poor nu-

25

FACTORS THAT INFLUENCE WHAT A PRIMARY HEALTH WORKER CAN DO

Factors influencing personal potential ofVHW

• cultural background • level of literacy influencing• personal factors:

- compassion- integrity- judgment- initiative - perceptiveness - special talents - learning capacity

Local conditions:

• acceptance of VHW and program bycommunity

• health priorities within the community• available funding (from within the com-

munity)

Outside decisions and control.

• attitudes, open or preconceived, as towhat the VHW should be taught andpermitted to do

• length, content, quality and appropria-teness of training

• limitations of 'norms' imposed on healthworker by outside authorities (e.g. He-alth Dept.)

• ability or inability of instructors and su-pervisors to build upon the existing kno-wledge, skills and cultural perspectivesof the VHW.

• available funding (from outside thecommunity)

Intrinsic factors Extrinsic factors

26

trition, poor hygiene, low literacy andhigh fertility help account for the highmorbidity and mortality of the impove-rished masses. But as we all know, theunderlying cause -- or more exactly, theprimary disease -- is inequity: inequityof wealth, of land, of educational op-portunity, of political representation and

of basic human rights. Such inequitiesundermine the capacity of the peasantryfor self care. As a result, the political/eco-nomic powers-that-be assume an incre-asingly paternalistic stand, under whichthe rural poor become the politically voi-celess recipients of both aid and exploi-tation.

TOO OFTEN AID AND EXPLOITATION GO HAND IN HAND

In spite of national, foreign and interna-tional gestures at aid and development,in Latin America the rich continue togrow richer and the poor poorer. As an-yone who has broken bread with villa-gers or slum dwellers knows only toowell: health of the people is far more in-fluenced by politics and power groups,by distribution of land and wealth, thanit is by treatment or prevention of dise-ase.

The paper concludes that, "Political fac-tors unquestionably comprise one of themajor obstacles to a community suppor-tive program," In this context, we lookedat the implications in the training andfunction of a primary health worker:

If the village health worker is taught arespectable range of skills, if he is en-couraged to think, to take initiative andto keep learning on his own, if his judg-ment is respected, if his limits are deter-mined by what he knows and can do, ifhis supervision is supportive and educa-tional, chances are he will work withenergy and dedication, will make a majorcontribution to his community and willwin his people's confidence and love.His example will serve as a role modelto his neighbors, that they too can learnnew skills and assume new responsibili-ties, that self-improvement is possible.Thus the village health worker becomesan internal agent-of-change, not only forhealth care, but for the awakening of hispeople to their human potential. . . andultimately to their human rights.

However, in countries where social andland reforms are sorely needed, whereoppression of the poor and gross dispa-rity of wealth is taken for granted, and

where the medical and political establis-hments jealously covet their power, it ispossible that the health worker I havejust described knows and does and thinkstoo much. Such men are dangerous:They are the germ of social change.

So we find, in certain programs, a diffe-rent breed of village health worker isbeing molded . . . one who is taught apathetically limited range of skills, who istrained not to think, but to follow a list ofvery specific instructions or 'norms', whohas a neat uniform, a handsome diplomaand who works in a standardized cementblock health post, whose supervision isrestrictive and whose limitations are ri-gidly predefined. Such a health workerhas a limited impact on the health andeven less on the growth of the commu-nity. He--or more usually she--spendsmuch of her time filling out forms.

E.NETWORKING: FROM NATIONAL TO REGIONAL

Through these study visits and the ex-changes that began to develop, membersof the grassroots, non-government "com-munity supportive" programs recognizedthey had a lot in common, could learnmuch from each other, and be supportiveof one another in difficult times. Associa-tions and networks began to form.

The early associations were within a sin-gle country. In Mexico it was PRODUS-

27

SEP. In Guatemala, ASECSA. In Nicaragua,CISAS and PROSALUD. Soon nationalassociations began to arrange internatio-nal encuentros (encounters), out ofwhich evolved a new sense of solidarity.It was clear that the social determinantsof health were similar throughout LatinAmerica. Some countries were nominallydemocracies and others were indispu-tably dictatorships. But in virtually everyone a rich, powerful ruling class ran thegovernment and wielded debilitatingcontrol over the impoverished majority.What was more, the oppressive headsof state often were put into power andpropped up by the US government, andwere in league with the powerful trans-national corporations that had controllinginterests in Latin American politics andbusiness. In country after country, whenthe poor majority dared choose a leaderwho put the health and rights of the pe-ople above profiteering of transnationalcorporations, the US government-corpo-rate complex overtly or covertly interve-ned. The CIA, through mercenary troopsor military coups, assured the disposalof the progressive leader, replacing himwith a business-friendly puppet-tyrant.With this agenda, the United Fruit Com-pany helped engineer the overthrow ofPresident Jacobo Arbenz in Guatemala,and the US Anaconda Copper industryengineered the assassination of electedpresident Salvador Allende in Chile andhis replacement with the ruthless dictatorPinochet. The story is similar in countryafter country.

In the international encuentros of com-munity health programs, as participantsanalyzed the root causes of poor healthin their respective countries, it became

painfully clear that an overriding deter-minant of health -- even in the smallest,most isolated village -- is the top-heavyglobal economic system, controlled by avery small but incredibly powerful rulingclass. People in a remote village -- oreven a small country -- can work collecti-vely to improve local conditions affectingtheir health. But as our interconnectedglobal crises -- political, economic, andenvironmental -- become more all-con-suming, the need for a united worldwidepopular front is even greater.

It was the common concern about socialinjustice as the mega-determinant of he-alth that spurred the national associationsin Mesoamerica to join forces. In 1975 agroundbreaking Encuentro was organizedin Emaus, Guatemala. This gave birth toEl Comité Regional de Promoción de Sa-lud Comunitaria – or CRPSC (RegionalCommittee for Community Health Pro-motion) covering Mexico, Central Ame-rica, and the Caribbean. The agenda ofthis new coalition was radical, in thesense that radical means getting to theroots. Everyone recognized that Healthfor All would only be possible though acollective people-centered effort -- bothlocal and international -- to transform thedominant neoliberal socioeconomicsystem. The prevailing paradigm, desig-ned to benefit the privileged few at hugehuman and environmental costs, has toyield to a harmonious approach that be-nefits all: a system that is truly democratic,egalitarian, and humane -- founded onuniversal human rights.

Was this a utopian dream that grew outof the rebellious '60s? Perhaps. But inthe long haul, we all realized that the fu-ture of humanity -- indeed, the very sur-

28

vival of our species -- depends on trans-forming our current super-macho socialorder that caters to greed, to a gentler,more feminine order that answers tocommon needs. It depends on our achie-ving an all-inclusive egalitarian system inwhich we all live collectively and com-passionately, for the common good.

F.REACHING OUT TO OTHERPARTS OF THE WORLD

Over time, the Regional Committee forCommunity Health Promotion (CRPSC)

gradually expanded to include morecountries of the Caribbean and represen-tatives from programs in South America.Also they began to have exchanges withlike-minded programs and networks inother parts of the world.

For example in 1980, Martín Reyes, oneof the lead village health workers of Piax-tla, in Mexico, had a chance to visit Indiafor an international health conference ti-tled, "Let the Village Hear." As it turnedout, Martín was one of only a few villagerspresent at the conference. Yet his impactwas transformative: Martín stressed theneed for more villagers to have a chanceto speak up rather than to just be talkedabout -- the concept of "nothing aboutus without us." The conference closedwith an official decision to change itstheme from "Let the Village Hear" to "Letthe Village Be Heard."

The following year, in August 1981, a uni-que interchange was arranged betweenvillage health workers from Central Ame-rica and the Philippines. A group of healthworkers from programs in Guatemala,Honduras, and Mexico traveled to thePhilippines, where they exchanged ideaswith health workers in the country-widenetwork of Community Based HealthCare programs there.

This interchange was a great stimulus forall of us, from both sides of the Pacific.We realized how much the countries ofLatin America and the Philippines had incommon, both historically and in the pre-sent: first the conquest and colonizationby Spain, then neo-colonization by theUnited States. There were strong parallelsbetween the rape of the land and thepeasantry by United Fruit in the Americas,

29

and by Del Monte in the Philippines. Inboth cases the US military-corporatecomplex propped up dictators who bo-wed to its neoliberal agenda.

All in all, in the exchanges between healthworkers from distant lands -- and the "si-tuational analyses" that they presentedof their respective homelands -- engen-dered a new sense of international andintercontinental solidarity. By sharing sto-ries of their similar sufferings and strug-gles, everyone could see that the majordeterminants of poor health, in all ourcountries, are rooted in the increasinglyglobalized, cruelly inequitable economicsystem. Clearly, the so-called "free mar-ket," despite its lip service to democraticprocess, is designed to favor the rich andpowerful. Despite all the rich countries'token gestures of "international aid" andthe non-binding mandates of the UN,the gulf between rich and poor has con-tinued to widen between countries andwithin them. And despite the "UniversalDeclarations of Human Rights," the mostbasic rights are routinely violated with im-punity -- especially the rights to adequatefood and universal health care.

G.INTERNATIONAL NETWORKSAND GLOBAL CHALLENGES

As the social determinants of health be-came more central and overbearing, thenetwork in Mesoamerica sought to ex-tend communications and solidarity with

parallel groups in other parts of the world.Over the years more far-reaching coali-tions were formed, with much of thegroundwork spearheaded by the Regio-nal Committee and its associated orga-nizations.

In the '70s and '80s, when the WorldBank was forcing its neoliberal trade po-licies and Structural Adjustment down thethroats of heavily indebted nations, theplight of the underclass and the harshdisciplinary measures by national rulersadded fuel to the fire of popular resis-tance. In Latin America, the marginalizedwere mobilizing a struggle for liberationfrom their heavy-handed ruling classes.

In these popular struggles for liberation,the networks of grassroots community-based programs played a significant role.In some cases these struggles were suc-cessful -- at least temporarily. In a fewcountries the old plutocracies gave wayto more democratic, more people-sup-portive governments. In others, the strug-gle for liberation appeared to be gainingground.

In the Philippines, which has a lot in com-mon with Latin America, there had longbeen smoldering resistance to the des-potic US-supported Marcos government.At last Ferdinand Marcos was overthrownin the massive, largely non-violent, po-pular uprising called the "Revolution ofFlowers." Thousands of people marchedon the soldiers and put flowers in theirguns. And the astounded soldiers listenedto their hearts and sided with the people.... But this didn't just happen out of no-where. The Community Based HealthCare Movement, whose health workersreached nearly every town and village,

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had played a strong underground role inmobilizing and preparing the people. Nu-merous socially minded doctors, nursesand nuns, as well as community healthworkers, had been jailed or killed. Butthis had only strengthened the people’sresolve. And at last the puppet dictatorwas ousted.

Of course the people's victory was onlypartial. The global power system corpo-rate imperialism remains intact -- andsoon a new group of puppet heads ofstates took control, It is a similar story inmany parts of Earth. But at least the pe-ople are awakening, and the powers-that-be are increasingly on the defensive. Aluta continua.

H.PARTIAL SETBACKS IN STRUGGLES FOR SOCIALCHANGE

As already indicated, the country in Cen-tral America where the Liberation Struggleappeared most successful -- at least fora while -- was Nicaragua, where in 1979the Sandinistas overthrew the Somozadynasty. This was the shining successstory of "poder popular" -- or power bythe people. Through avid promotion ofuniversal health care and countrywidecampaigns to promote literacy and era-dicate endemic diseases such as polio,malaria, and dengue, by the mid-'80s Ni-caragua had achieved astounding impro-vements in the basic indicators of health

(child survival, maternal mortality, greaterlife expectancy).

To celebrate and learn from these remar-kable achievements -- and to examinethe key role played by community mobi-lization in the struggle for change -- someof us in the Regional Committee, togetherwith community health pioneers in otherparts of the world, began to plan an in-ternational symposium. The event, called"Health Care in Societies in Transition,"was planned for 1998 in Managua. Wefelt that those countries around the worldengaged struggles for health and socialjustice had much to learn from Nicaragua.To this end we invited health activistsfrom various countries where grassrootsstruggles for change were underway --notably South Africa, India, Bangladesh,the Philippines, Palestine, and several La-tin American countries.

The date originally set for the symposium-- 1988 -- was repeatedly postponed, un-til 1990. In those two disturbing yearsthe global situation changed, in someways for the worse. The Nicaraguan vic-tory had threatened to demonstrate thatan alternative model to the one advoca-ted by the global elite could work welland provide far superior health, welfareand educational opportunities to the pe-ople. Although Nicaragua is only a smallcountry, such a demonstration could havefar reaching consequence. This could notbe tolerated by the global elite, and ithad to be undermined at all costs. Sothe United States, under Ronald Reagan,initiated economic embargos and a pro-gram of counter-revolutionary terrorismcarried out by the Contras. These actionswere clearly in violation of a variety of in-ternational laws:

31

• The Nuremberg Principles.

• The United Nations Charter.

• The Inter-American Treaty of ReciprocalAssistance (Rio Pact).

• Rome Statute of the International Cri-minal Court.

It is a strange world, indeed, when simplyasking that the United States comply withinternational law must be seen as radical.Beyond this it is worth noting that theContra's were largely financed by thelaundering of weapons sales through theMiddle East that came to be known asthe Iran-Contra scandal.

It is important to see this attack on Nica-ragua and other central and south Ame-rican countries in the larger context ofthe world economic system. The currenteconomic system that is centered in theUnited States and dominated by multi-national banks and corporations has pla-ced the collective health and survival ofhumanity in graver danger than ever be-fore. It would be absurd to expect thatan economic system that is motivatedby greed, organized for domination, andinadequately regulated should paradoxi-cally provide for the health and wellbeingof the planet and its people. To the con-trary, this system now threatens the well-being and the very existence of our spe-cies because of the Pandora's box ofproblems that it has created:

• the growing gap between rich and poor

• the eroding of what little there was ofdemocratic process

• the growing toll on health through thewithdrawal of public systems of healthand welfare

• the endless conventional war and thethreat of nuclear war

• economic meltdowns

• the use of the mass media to distractand misinform the people through themerging of news, propaganda and en-tertainment

• the damage to our food system thoughthe unregulated and experimental cre-ation of genetically engineered crops

• a growing shortage of clean water

• the turning of our environment into acarcinogenic pool by nuclear and che-mical wastes we cannot dispose ofpeak oil

• the unbridled exploitation of non-rene-wable energy resources

and, last but not least -- as the result ofall this ever-increasing exploitation of pe-ople and the environment, looms thebiggest threat to humanity and to life onthe planet: GLOBAL WARMING.

The enormity and interaction of these cri-ses leads to pandemic despair and vio-lence. It is a Pandora's box full of horrors.We are fast approaching a turning pointwhere there may be no turning back. Yetthe world's top politicians, bought off orintimidated by the multinational banksand corporations, have no interest in ta-king the radical steps that are needed.

The overall influence of the Catholicchurch also played its part in rolling backsome of the gains we saw in Nicaraguaand elsewhere, though the facts here arecomplex. The Church became dividedbetween the traditionalists who stood up

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33

for the top-heavy status quo, and theTheology of Liberation, which followedthe teachings of Christ by siding with theoppressed. Many priests and nuns, mo-tivated by the theology of liberation, stoodup as powerful voices for a more just so-cial order, and for their courageous standssome paid with their lives. Yet, it seemsclear that the church hierarchy was atbest lukewarm with regard to people'sstruggles for their rights.

In Nicaragua, the institutionalized terro-rism perpetrated by the United States,the embargo and other more sophistica-ted strategies of social control took theirtoll. In 1990 --shortly before the sympo-sium finally took place, the Sandinistaswere voted out, and the conservativeUNO coalition party, propped up by theCIA, took power. It was a familiar story ofUS imperialism. The US had made it clearthat the devastating "counter-revolution"would continue until the Sandinistas fell.The Nicaraguan population, exhaustedby the endless mercenary violence andduped by UNO's false promises, finallygave in and voted yes for defeat.

Once UNO was in power, many of theinequities of the old regime resurfaced.Public services were cut back, medicalcare was privatized, and health statisticsdeteriorated accordingly. This can be seenon the graph in the next page.

So the long-awaited Symposium on He-alth in Societies in Transition, initially plan-ned to explore positive transitions towardmore equitable, health-promoting gover-nance, was instead revised toward analy-zing the current negative transitions, andto strategize on how to preserve whatevergains had been made before the tides

turned and things regressed in an unhe-althy direction.

For all these troubling reversals, the Ma-nagua Symposium broke new ground.There was penetrating analysis, and solidproposals for local and international ac-tion. Through the open exchange amonghealth activists from Asia, Africa, the Mid-dle East, and the Americas -- the similarityof problems faced in different corners ofthe Earth was unmistakable. A strongsense of denationalized solidarity emer-ged. During the closure, the group agreedthat the exchange that had begun nee-ded to continue and expand. To this endthey formed a new intercontinental coa-lition, called the "International People'sHealth Council" (IPHC).

During the 1990s the IPHC arranged pe-riodic international gatherings, held inSouth Africa, Palestine, Europe, and Aus-tralia. Conjointly it facilitated short courseson topics such as Health Education forChange, Child-to-Child activities, grassro-ots organization, and other action-orien-ted topics.

Towards the end of the 20th Century, keyplayers in the IPHC and the Regional Com-mittee, together with other national andinternational health networks, began toplan of a turn-of-the-century global confe-rence, named the People's Health As-sembly. This was held at GonashasthayaKendra in Bangladesh in December, 2000.The "PHA" was attended by over 1400health workers and activists from morethan 70 countries. Out of this groundbre-aking Assembly emerged the ongoing Pe-oples Health Movement (PHM), whichhas held subsequent assemblies in SouthAfrica and here in Ecuador.

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SOMOZA SANDINISTAS

CURATIVE ASPECTS

PREVENTIVE SERVICES

IMPACT ON HEALTH

CHAMORRO

CONSERVATIVEDoctors and hospitals

for urban rich

Too costly and inaccessiblefor the poor majority

REVOLUTIONARYPeople based rural and community health posts

Free services accesible to almost all

MARKET ORIENTEDNeoliberal, many health posts

closed down

privatization and cost recoveryput services out of reach

Did very little preventivework

Excellent preventive campaigns

Preventive workdesired...

...but unable to mobilize people

Poor health and veryhigh child mortality

Rapid health improvementand fall in child mortality

Stagnation and reversals inhealt and child mortality

Currently -- with thousands of members,a diversity of national and regional pro-grams, numerous watchdog groups, anda foot in the door of the World HealthAssembly -- the PHM now adds a sobe-ring "voice of the people" to the discus-sions of the world's top planners and de-cision-makers in health-related concerns.And -- as all of us here know -- a regionalarm of the PHM is El Movimiento para laSalud del Pueblo-America Latina (MPS-LA), now engaged in its first internationalconference, in which we are gathered.

I. NEED FOR EVOLUTION ASPART OF REVOLUTION

Unfortunately, the high expectations forhealthier, more fully democratic rule fo-llowing the overthrow of oppressive regi-mes in the late 20th century often turnedto bitter disappointment. In Nicaragua afterSomoza, in the Philippines after Marcos,and in South Africa after liberation fromapartheid rule, people's hope for radicalchange was high. But within a few yearsreversals took place, back toward the top-down, cruelly polarized social order of be-fore. Even for a revolutionary as visionaryas Nelson Mandela, the overarching po-

wer of the globalized plutocracy was justtoo much.

What is more, with the victories over theold regimes in the late 1900s, and theglobal dream of Primary Health Care forAll by the Year 2000, subscribed to by allmembers of the United Nations, many ofthe popular organizations and communityhealth programs let down their guard.Many of the long-struggling grassroots he-alth programs quietly disappeared, orwere absorbed by new government ex-tension services with such progressive-sounding names as, in Mexico, "SeguroPopular," and "Solidaridad."

What can we learn from the fact that somany "Struggles for Liberation," after over-coming oppressive regimes, gradually slipback to the old pecking order, with a newbatch of tyrants rising to the top? The chieflesson, perhaps, is that revolution withoutevolution doesn't change much -- or atleast not for long. If we are looking for ra-dical change of governance, we have firstto build a radical change in the way ordi-nary people see themselves in relation toother people and natural world. And muchof this has to do with the way they aretaught, from the time they are children.For this reason, if we as a people are toadvance, through transformational evolu-tionary struggle, toward a healthier, kinder,more sustainable social order, we needto start with our children -- and specifically,with how they learn.

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IV. HeaLtH eduCatIonfor CHange

37

This historical sketch of the Struggle for Health in Latin Americawould not be complete without underscoring the methodology of"Liberating Health Education" which evolved as part of the move-ment.

In today's polarized society, "education" is a two-edged sword. Abetter name might be "Indoctrination," or "Obedience Training."A major purpose of public schooling, as it exists today, is to condi-tion young people to follow rules and obey laws, no matter howjust or unjust. It is to mold students into subservient workerswilling to do repetitive tasks for miserable wages under orders ofa commanding patron. The need to prep children for such degra-ding jobs perhaps explains why schooling tends to be so boringand authoritarian. Rather than encouraging youth to think inde-pendently, or analyze their life situation, they are compelled tomemorize heaps of dates and data, regardless of how true oruseful. What passes for "Education" has become the science ofturning young people into smoothly oiled wheels of a heartlessmachine that churns out more wealth and power for the rich andpowerful. This kind of "education" is an instrument of socialcontrol. Of institutionalized oppression.

But education needn't be like this. It can be an instrument of libe-ration. Indeed, an empowering approach to learning is essentialto any grassroots movement for a fairer, healthier social order.

Latin America has been a leaderin developing an approach toeducation that is potentially li-berating -- in the sense that ithelps people figure out the un-derlying determinants of healthand work together to improvetheir situation. Key to a liberatingapproach to learning -- or "Edu-cation for Change" -- is the rea-

To learnis to change

lization that everyone has valuable kno-wledge and experience, and that we canall learn from one another other, asequals.

The most well-known proponent of Edu-cation for Change in the last century wasthe Brazilian adult-literacy facilitator, PauloFreire. Freire's classic book, Pedagogy of

the Oppressed, revolutionized the me-thodology of information sharing and"concientización" (awareness raising) incommunity-action movements world-wide.

As many of you may already know, Freiredescribes two of kinds of education.

The first is the "banking" approach, wherean all-knowing authority deposits ideasinto his or her pupils' empty heads.

The second is the "liberating" approach,where the facilitator pulls ideas out ofthe heads of the learners, and helps thembuild on their own observations and ex-perience.

In the "learning forchange" approach ad-vocated by Freire,everyone's ideas andexperience matter.Everyone learns fromeach other. Peoplecollectively analyzethe situation in whichthey live, discuss theircommon problems,and examine the un-derlying causes. Thenthey plan a collectivecourse of action, ca-refully weighing thepotential risks and be-nefits. Freire insistedthat through such anawareness-raising, ac-tion-oriented process,a self-empoweredgroup of people can"change the world."

In Latin America, the Philippines, and el-sewhere, health workers have adaptedPaulo Freire's ideas to community healtheducation. Through trial and error, theyhave come up with their own approachesto collectively analyzing health-related ne-eds, figuring out solutions, and accom-modating them to the local situation.

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paULO Freire

39

In Guatemala, Nicaragua, Chile, and Me-xico, health educators experimented with"key pictures" as community "discussionstarters" to get people talking about con-cerns that affect their well-being. For thispurpose, Freire had advocated "keywords." But health promoters found thata provocative picture could often stimu-

late group discussion or major concernmore effectively. Here are examples of"pictorial discussion starters" used in thehuge slum community of Netzahuacoyotlon the outskirts of Mexico City, wherehigh cost of food, and heavy-handedabuse by authorities, are seen as majorobstacles to well-being.

THE AIMS OF HEALTH EDUCATIONBEHAVIORS CHANGE

GLOBAL

POWER

STRUCTURE

SOCIAL CHANGE

In education that focuses on behavior and at-titude change, people are acted upon by the

sistem and the world that surrounds them.

In education that works for social change, pe-ople act upon the system and the world thatsurrounds them.

OR

I AM GOINGTO CHANGE

YOU!

WE AREGOING TO

CHANGE YOU!

EDUCATION OF AUTHORITYputting ideas in

EDUCATION FOR CHANGEpulling ideas out

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HUNGER

TELEVISION

WHY IS THERE HUNGER? WHAT CAN WE DO TO END IT?

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POLICE AND COURT

A good example is the "parrot picture" --a drawing I first saw used in the BehrhorstHospitalito in Guatemala (used as a dis-cussion-starter by our fellow health edu-cator, María Zuniga)

The facilitator starts by asking somethinglike, "What do you see in this picture?"and perhaps, "Why doesn't the parrot flyaway?" Usually this triggers a lively dis-cussion that leads to questions about thepsycho-social disempowerment of los deabajo (the underclass) as a strategy ofbehavioral training and social control. Atsome point the facilitator may want toask, "In what ways is this parrot like us?"but usually the question comes from thegroup. The facilitator must take care tolet participants take the discussion wherethey choose: that is, to pull ideas out ra-ther than push them in.

This parrot picture has proved to be oneof the most provocative discussion star-ters, to get disadvantaged people talkingabout their hardships, underlying causes,and how to gain more of a voice in thefactors that determine their health andtheir lives.

A.THE MEASLES MONSTER

At the same time as this workshop,MINSA had organized a vast national im-munization Jornada against measles.They asked us, in the workshop, to ex-plore ways to get the people more invol-ved and less suspicious. In those days abig obstacle to effective immunizationwas a disinformation campaign triggeredby the United States Central IntelligenceAgency. The CIA had funded various con-servative evangelical groups and privateUS charities to spread rumors throughoutNicaragua that "vaccination causes steri-lization and impotency." (To prove this,they pointed out the word "sterilized" onvials of distilled water used with the vac-cines.) So lots of people were afraid toimmunize their children.

To counter this malicious disinformationand educate people about the lifesavingimportance of vaccination, workshop par-ticipants involved the local community increating a street theater skit called "TheMeasles Monster."

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43

The skit opens with ahuge, fearsome monsterchasing after and infec-ting unvaccinated chil-dren (photo 1).

One sick child nearlydies. But when his pa-rents discover that therumors about steriliza-tion are lies, they insistthat all children be vac-cinated.(photo 2).

Then a large group ofchildren -- now protec-ted and strengthened bythe vaccine -- attack andovercome the MeaslesMonster. At the close ofthe skit, the jubilant chil-dren cry out, "¡Los niñosunidos jamás serán ven-cidos!" (The childrenunited shall not be over-come!) (photo 3).

The skit of "The MeaslesMonster" -- which is in-cluded in the Spanishedition of Helping He-alth Workers Learn -- hasbeen enacted or adap-ted to local themes andcircumstances in manycountries. The processof community empo-werment is contagious.

pHOt

O 1

pHOt

O 2

pHOt

O 3

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B.COMMUNITY DIAGNOSIS

Different programs used different methods to help people analyzetheir health-related needs and explore solutions. To engage groupsof farm workers, mothers, or schoolchildren in a "situational analy-sis," many promotores begin with a "Community Diagnosis."

The group identifies their common health-related problems, whichthey label according to Frequency, Severity, Contagion, and Du-ration. Next they look at which problems contribute to other pro-blems, and how.

For all this they use pictures, because pictures speak louder thanwords, and because with pictures, people who can't read or writecan participate equally. Participants make their own simple dra-wings to create a colorful display of their Community Diagnosis.Finally they discuss which problems they should try to attack first,and try to develop a plan of action. Because the activity is sovisual and hands-on, nearly everybody gets involved. It is an eye-opening, action-oriented learning experience ... and lots of fun.

C.STORYTELLING, THE'BUT WHY?' GAMEAND THE 'CHAINOF CAUSES’

One widely used methodto help people learn aboutinterrelated causes of diffe-rent health problems usesstorytelling, followed by a"But why?" game, and thecreation of a "chain of cau-ses." First, a true story is told, perhapsabout the recent death of a child. Intothe story is built a whole series of causes,one leading to the next. After the story istold, the learning group retells it back-wards, and each time a cause is stated,everyone asks, "But why?"

The process is in four parts:

1. The story relates a series of eventsthat lead to a tragic ending, such asthe death of a child. (People's attentionis captured better if it is based on a re-cent, local sequence of events ever-yone is familiar with.)

2. After the story, participants play a (veryserious) 'But why?' game, in whichthey itemize and analyze the series offactors leading up to the child's death

3. Next, they collectively build a Chain ofcauses leading the sick child to thegrave. To make this more lively and"hands on," the links of the chain, aswell as a graphic of the child and the

grave, can be cut out of cardboard.

The links, labeled with symbolic dra-wings, initially represented 5 types ofcauses:

• physical (things)

• biological (worms and germs)

• cultural (beliefs and attitudes)

• economic (having to do with moneyand who has it)

• political (having to do with powerand who has it)

To these five categories of causes,we later added a 6th type ...

• environmental (having to do withecological balance)

This extra link for environmental causeswas added because disturbances in eco-logical balance have become such a ma-jor threat to health, locally and globally,in recent times.

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4. Finally, the group explores which linksof the causal chain they may be ableto break in order to prevent similarloss of health and life in the future.They ask themselves:

• Which links can be broken by thecommitted action of a single person?

• Which links require action at the fa-mily or village level?

• Which require action at a national le-vel? At a global level?

• What is the likelihood of successfullybreaking different links?

• What preparations and resources areneeded? What are the risks?

• With which links can we most effec-tively begin to take action?’

In our handbook, Helping Health WorkersLearn, the 'Chain of Causes' is presentedthrough the "Story of Luis," a child in aMexican village who died of tetanus inthe early years of Project Piaxtla, whenimmunization of children was just beingintroduced. The story points out howquestions of land tenure, share-cropping,flooding due to deforestation, failures inthe health system, institutionalized co-rruption, and the profiteering of drugcompanies all contribute to the causalchain leading to Luis' death.

Through such graphic dissection of thecomplex chain (or web) of causes leadingto one child's tragic death, the communitygains a broad view of the contributing fac-tors. Then they can begin to formulate arealistic plan of which links they can firsttry to break, and what kind of preparationand action is required. And as we have alllearned the hard way, weighing possiblerisks against benefits is essential

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D.DISCOVERY BASED LEARNING

The "Chain of Causes" is one of themany methods we health educators call"Discovery Based Learning," an approachpioneered in the community based pro-grams in Latin America, and elsewhere.Such methods are in tune with Freire's"Education of Liberation" because peoplecritically analyze the interlinking determi-nates of health and then embark on areasoned plan of action.

As mentioned, a selection of these "dis-covery based" methods is included inHelping Health Workers Learn, a follow-up handbook to Donde No Hay Doctor.The idea for this latter book came fromthe previously mentioned study trip agroup of us from Project Piaxtla, in Me-xico, took to visit community health pro-grams in Latin America. In the differentprograms, we saw marvelous examplesof health education tools addressing awide range of health-related problems.Everyone, at least in the community sup-portive programs we visited, was interes-ted in sharing ideas and learning more.

So we decided to pull together a collec-tion of "Education for Change" learningmethods and publish them for anyoneto draw on. However, this turned out tobe easier said than done. To facilitate thesharing of methods and ideas, at the cen-ter of our village health program (Piaxtla)in the village of Ajoya, we organized aseries of Intercambios Educativos (Edu-cational Exchanges). To these we invitedhealth promoters from the various coun-

tries in Mesoamerica. Our challenge wasnot just to have participants demonstrateexisting methods, but to encourage anddevelop creativity: to invent new methodsand learning aids.

So first we asked folks from differentcountries to demonstrate one of theirmost unique and successful teaching me-thods or materials. Next everyone com-mented on the strengths and weaknes-ses of what they'd seen. And finally, we'ddivide into small groups, each with parti-cipants from different countries. Eachgroup would then try to improve one ofthe methods or aids they had seen, oruse the method as a launching pad for anew and different approach.

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The outcome was a wealth of exiting me-thods, games, devices, and ideas -- manyof them highly participatory, analytical,and thought-provoking -- aimed at co-llective action to cope with or correctcommon health-related concerns. Hel-ping Health Workers Learn contains a dis-tillation of these methods, together withexamples from health initiatives in diffe-rent parts of the world. Throughout thebook, there is strong emphasis on thesocial determinants of health. In fact, theintroduction is titled "Why this book is sopolitical," because it is so clear that "Thestruggle for health is the struggle for socialjustice.”

E.CHILD-TO-CHILD

Speaking of Education for Change, Iwould like draw your attention to whatfor me has one of the most exciting de-velopments to emerge out of the peo-ple-centered struggle for health. I speakof the Child-to-Child initiative, in whichLatin America has played a key and insome ways revolutionary role.

The Child-to-Child concept did not origi-nate in the Americas. It grew out of aninternational gathering of health educa-tors in 1979, convened by David Morley,a pediatrician with long experience in ru-ral Africa, and a leading pioneer in Pri-mary Health Care. I had the good fortuneto attend this seminal meeting. The ideafor Child-to-Child emerged from the fact

that in very poor families often the per-sons who spend most time caring for ba-bies and toddlers are not the parents,who often are gone from dawn to darkworking to feed the family. Rather, theprimary care providers tend to be the in-fants' somewhat older brothers and sis-ters. Often young children, especially girls,are kept out of school because they are

needed to care for their younger siblingswhile their mother is working.

So the original goal of Child-to-Child wasto help school-aged children -- whetheror not they go to school -- to learn toplay an active role in protecting the healthand stimulating the development of their

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“If in truth we are going to achievepeace in this world, we will have tobegin with the children”.

Mahatma gandhi

to transform the world we first need totransform the educational system.

younger brothers and sisters. A variety ofChild-to-Child "activity sheets" were de-veloped to help children learn preventive,and curative skills regarding the health ofyoung children. In some cases these skillswere life-saving Early activities addressedtopics such as diarrhea, lowering fever,getting enough to eat, cleanliness, pre-vention of accidents, and so on.

Since its modest start, the concept ofChild-to-Child -- now practiced in morethan 70 countries -- has expanded in anumber ways. In many programs, scho-olchildren in older grades are now invol-ved in teaching Child-to-Child skills tothose in younger grades. And the range

of activities has grown. Now children notonly help meet the health needs of youn-ger siblings, but play a role in communityactivities, ranging from home gardens, totree planting, to recycling garbage as fer-tilizer, to care of the elderly.

From the first, the teaching methods ad-vocated for Child-to-Child were "child

centered": they relied on things the childcould see and touch, they engaged thechild's active participation, they encoura-ged thinking and exploration, and theywere fun. But in practice -- particularly inschools -- too often the teaching stylewas still very didactic and top down: "Do

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tHese cHiLdren are tHe priMary caretakers OF tHese babies. a: this girl manages to take good care of her baby sister. b: this girlhas not managed to take Good care of her baby brother.

this! Do That!" Children were simply as-ked to memorize things and told what todo, As ever, teachers pushed ideas intothe children's heads, rather than encou-raging them to build on their own expe-riences and observations.

This is where Latin America has made itsbig contribution to Child-to-Child, helpingto transform it from an useful but fairlyorthodox teaching tool to a liberating le-arning experience. The transformative po-tential of Child-to-Child should not be un-derestimated, either for children or forschools. Standard schooling, as the"Schoolboys of Barbiana" describe, is toooften "a war against the children of thepoor." It teaches the young to follow or-ders, to compete against each other, andto memorize and vomit back boring in-formation -- or misinformation -- that haslittle to do with their day-to-day needsand lives. It challenges them to passexams, rather than to think for themselves.

By contrast, Child-to-Child, in its more li-berating form, encourages children make

their own observations, draw their ownconclusions, and take collective action tosolve problems in their own homes andcommunities. Thus Child-to-Child, whenpracticed in the schools, can help makeschooling more relevant to their lives.

Latin America, as the leader in this libe-rating, discovery-based approach to Child-to-Child, has begun to disseminate it toother parts of the world. Project Piaxtla,the village health program in Mexico, pla-yed a key role in developing the earlyChild-to-Child "Activity Sheets," whichwere then translated and distributed in-ternationally. In the early '80s, a lead pro-motor in Piaxtla was Martín Reyes, wholoved the concept of Child-to-Child be-cause, as a boy, he'd begun volunteeringin the program. So Martín facilitated theearly trials of various activities. As a tea-cher of health workers, he was well ver-sed in the facilitation of "discovery basedlearning," and he built this empoweringmethodology into the Child-to-Child ac-tivities he helped develop.

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NIÑO A NIÑO EN LATINOAMÉRICALos niños como agentes de cambio.

Los niños aprenden a:

l Pensar por sí mismos.l Incluir a todos; no excluir a nadie.l Defender a los que son más débiles o despreciados.l Hacer sus propias observaciones y llegar a sus propias conclusiones.l Analizar sus problemas comunes y trabajar juntos para resolverlos.l Más cooperación, menos competencia: buscar soluciones juntos.

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The Regional Committee of CommunityHealth Promotion, helped spread Child-to-Child methods to other countries andprograms. A big boost came when Martínwon an Ashoka Fellowship, to promoteChild-to-Child through Latin America. Ourcompañera Maria Zuniga, coordinator ofthe Regional Committee, helped Martínset up a base at CISAS (Centro de Infor-mación y Servicios de Asesoría en Salud)in Nicaragua. For 5 years he led works-hops for future Child-to-Child facilitatorsthroughout the region. In these trainingworkshops, Martín always insisted on ha-ving children participate. That way, thefuture facilitators would learn thoughhands-on practice, not just theory ... and

would learn not just about children, butwith them and from them.

To begin the Child-to-Child experiencewith a group, Martín likes to start by ha-ving the kids conduct their own interactive"Community Diagnosis," using colorfulpictures they make themselves.

This helps the kids look at "the larger pic-ture of sickness and health" in their villageand to visualize how the various healthproblems are linked together. Often, ba-sed on their findings, the children choosewhich health problem about which theywant learn first, and about which theywanted to explore possible solutions.

the children begin by doing their own community diagnosis

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F.EXAMPLE OF CHILD-TO-CHILDDISCOVERY BASED LEARNING:THE GOURD BABY

When village children discuss the mosttroublesome health problems in theirown home, diarrhea often tops the list.And with good reason. Worldwide, diar-rhea remains a top killer of young chil-dren, along with pneumonia, especiallyin impoverished families with insufficientfood and sanitation. Notable, however,in some places where Child-to-Child ispracticed, mortality from diarrhea hasdropped amazingly.

So let's take a look at the Child-to-Childactivity on diarrhea, and see how the dis-covery-based learning as practiced herein Latin America can make a real diffe-rence.

The first version of the Diarrhea activitysheet, developed in Africa, had some

good features. It used clear graphics andsimple language. To teach children aboutdehydration, it showed drawings of abowl with a hole in the bottom. Whenthe hole was plugged, the bowl stayedfull of water. When the plug was pulled,the water ran out. The children were toldthat the bowl represents a baby. "Whena baby loses too much water, it dries upand dies." The next thing the on the ac-tivity sheet was a list, with pictures, sho-wing the Signs of Dehydration: sunkensoft spot, no tears, dry mouth, scant urine,etc. The children were instructed to me-morize these signs.

The problem with this activity sheet wasthe teaching method. For all its colorfulimages, it was still top-down and didactic.Information flowed one way: from tea-cher to student.

There is an old saying: If I hear it, I forgetit; if I see it, I remember it; if I do it, iknow it.

To this, health educators in Latin Americahave added:

If I hear it, I forget it. If I see it, I remember it.

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¡ If I discover it, I use it!

With this in mind, the health workers inMexico came up with a teaching aid ca-lled the "Gourd Baby." They used a dou-ble-knobbed gourd: the kind farmers useto carry water. With the children's help,they painted the gourd like a baby ... and

put all the holes in it that a real babyhas. By filling the it with water, childrencan pull the plug in its backside to give itdiarrhea ... and observe what happens.

This way they discover for themselveshow the different signs of water loss -- ordehydration -- develop.

if I do it, i know it. ¡ If I discover it, I use it!

en el estado de Michoacán, México, se introdujo el aprendizaje de la deshidratación con el "bebé calabaza" en el currículo de la educación primaria.

To learn if such water loss can be dange-rous, they can pick some flowers in theschoolyard, put one flower in a bottlewith water and the other in a bottle wi-thout water, and leave them in the hotsun for a couple of hours. They see thatthe flower in water stays healthy, whilethe one without water wilts and dies.

"So what do you suppose happens whena baby loses a lot of water through diar-rhea?" the teacher asks?

"Maybe she wilts and dies, too," say thechildren.

"And how could you prevent that?" asksthe teacher.

"By giving the baby lots of water!"

Good thinking!

To find out how much water a baby withdiarrhea needs, again the children fill thegourd with water, and pull the plug. Onechild measures in cupfuls how much co-mes out. Another pours cupfuls of waterinto the top of the gourd. Half the classcounts how many cupfuls come out. The

other half counts how many are pouredback in. In this way, the children concludethey have to put in at least as much liquidas comes out.

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This direct observation is crucial -- be-cause researchers have found that a bigreason why oral rehydration sometimesfails is that caretakers often don't giveenough of the solution. But when chil-dren learn these things through their ownobservations, they are more likely to putthem to into practice. This can quite lite-rally save lives: it empowers the childrento think for themselves and take intelli-gent action.

The idea of the gourd baby has caughton around the world. CISAS, in Nicaragua,even uses the gourd baby as its logo.

Here is a photo of a local "gourd baby"in East Timor -- which health workersmade by gluing two coconuts together!

Today in Timor, this "coconut baby" isbeing used not only to teach childrenand mothers about oral rehydration, butalso to help health-workers and school-teachers learn about the empowering po-tential of discovery-based learning.

In Bangladesh, too, the idea of the gourdbaby has been widely used to teachschoolchildren about home managementof diarrhea. The method was first intro-duced as part of the Child-to-Child expe-rience by a groundbreaking communityhealth program named GonoshasthayaKendra -- or "GK" -- in the township ofSavar. Health workers there had learnedabout the liberating approach to Child-to-Child through exchange with programsin Latin America. In schools associatedwith GK, pupils in the upper grades ofprimary school teach the younger gradesabout management of diarrhea anddehydration, using a painted plastic bottleinstead of gourd.

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“bebé calabaza” hecho con dos cocos pegados en timor este.

The children shared what they learnedwith their families. And in the eveningsthey taught neighboring children whowere too poor to go to school. Throughthe spread of knowledge in this convivialway, and by the use of homemade rehy-dration drinks instead of commercialones, in GK's area of coverage the deathrate from diarrhea fell remarkably. Even-tually the Ministry of Education, impressedby GK's carefully documented achieve-ment, introduced the Child-to-Child diar-rhea activity into the national schoolsystem. But because double-knobbedgourds are rare in Bangladesh (as in Ti-mor) the Ministry mass-produced baby-

shaped plastic sacks with all thenecessary holes and plugs, sochildren could learn through thehands-on approach.

Over the following years in Ban-gladesh there was a dramatic re-duction in child mortality fromdiarrhea. The diarrheal death ratein Under-5s fell to less 20% ofwhat it had been 6 years before!This huge drop lowered overallchild mortality so much that Ban-gladesh -- which used to haveamong the highest child mortalityin the world -- is now showcasedby WHO as an example of "GoodHealth at Low Cost."

Clearly other factors have contri-buted to this impressive fall inchild deaths in Bangladesh. Butthere is little doubt that the intro-duction of this empowering me-thodology throughout the countr-y's schools has contributed topopular understanding of home-based diarrhea management that

has helped save hundreds of thousandsof children's lives. Another reason forthese remarkable gains, I suspect, is thatBangladesh has one of the most exten-sive networks of well trained, politicallyaware community health workers in theworld.

There are countless examples of howchildren, through this discovery based le-arning process, have helped save babieslives, even when they have been left athome as sole caretakers. I used to say,with tongue in cheek, that, "If all the worl-d's children could learn how to manageinfant diarrhea from the gourd baby, then

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bangla children teach each other about diarrea

they use a plastic bottle for the gourd baby

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the gourd baby -- with the children's help-- could save more babies lives than allthe world's doctors put together.”

This is, of course, not altogether true --mainly because dehydration is only thefinal link in the chain of causes leading todeath from diarrhea. Other links includemalnutrition, poverty, low wages, mal-dis-tribution of farmland, top-heavy free tradeagreements, corporate power, authorita-rian school systems, and the corruptionof democratic process -- not to mentionthe privatization of public services andthe wickedly high costs of commercialmedicine and doctors.

But it is precisely because these oppres-sive social determinants perpetuate thehigh rate of preventable illness and deathin the world today, that a more liberatingapproach to education is sorely needed.Our children will be the leaders and thefollowers of tomorrow.

G.USING CHILDREN'S "PARTICIPATORY EPIDEMIOLOGY"TO COMBAT MALNUTRITION

In the chain of causes leading to deathfrom diarrhea in children living in poverty,malnutrition is often the most perniciouslink. A well-nourished child who gets diar-rhea usually recovers. An undernourishedchild is far more likely to get thinner still,to get sick more often, and to die.

To combat death from diarrhea, oral rehy-dration therapy (ORT) only attacks thelast link in the causal chain: dehydration.To get closer to the root problem, wemust combat malnutrition. So in a disco-very based Child-to-Child approach, lear-ning about "Management of diarrhea"

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and "Combating under-nutrition" logicallygo hand in hand.

In Latin America, the Child-to-Child activitytitled "Helping children who are too thin"likewise takes a discovery-based, lear-ning-by-doing approach. It even engagesthe children as researchers in "participa-tory epidemiology" or epidemiologia par-ticipativa Infantil.

To start the activity, the teacher or facili-tator asks the group of children questionslike:

• Do you know of any babies or little kidsin the village who look too thin?

• Or who are all skin and bones?

• Do these little ones seem happy andhealthy?

• Why not?

• Why do you think they're so thin?

• What other problems do they someti-mes have?

• Are they in danger?

Then the children are encouraged to askrelated questions, such as:

• What do you suppose these very thinchildren need?

• What can we can do to help?

After discussing these and other ques-tions, and arousing the children's em-pathy, the teacher helps the class decideon a plan of action.

First, the children decide to conduct theirown house-to-house survey. To discover

Well fed

too thin

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which and how many pre-school childrenin their village are "too thin," they startby making simple measuring tapes -- orShakir stripes -- to determine the distancearound the upper arms of the all thesmall children under five years old.

They color these paper tapes in 3 zones:red, yellow and green, to show whicharms measure too thin, borderline, or OK.

After school the group of children spreadout through the village, measuring thearms of all "under-5s." With so many chil-dren taking part, they complete in oneafternoon a survey that would take anurse or health worker weeks.

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Next day back at school the young rese-archers pull together the results. Theycould do this with a graph on the black-board. But graphs can be hard for chil-dren to understand. So they use match-boxes, coloring them red, green andyellow to represent the Under-5 kids theymeasured. They stack the boxes in 3 co-lumns, to see how many fall into eachgroup.

"But what can we do they about this?"the children ask. This leads to a study ofhow to help toddlers who are "too thin"gain weight. They learn about a numberof simple, low cost measures that mighthelp. Things like:

• Feed the thin child more often -- at least 5 times a day [drawingChild-to-Child show]

• Make weaning porridges thicker(with less water, more calories)

• Add concentrated energy -- likecooking oil or mashed peanuts -- to the child's standard foods.

With this simple knowledge, theclassroom of primary school deci-des on a course of action. Eachyoungster who wants to (and mostdo) assume a responsibility for oneor two of the toddlers who mea-sured "too thin." They visit theirhomes before and after school,and do whatever they can to get abit more energy-rich food into thelittle bellies. Frequency of feedingcan be especially important. If bothparents are gone from dawn todark, the toddler may be fed onlytwice a day. Even if her stomach isfilled up each time, the toddler stilldoesn't get enough calories for

adequate nutrition. So a schoolchild'sfriendly visits, offering a snack of energy-rich food before and after school, cansometimes make a measurable diffe-rence.

And to measure that difference, after afew months of their collective action, theschoolchildren can repeat their survey.When this Child-to-Child nutrition activitywas first conducted in the village of Ajoya,Mexico, the schoolchildren discoveredfrom their follow-up survey 4 months la-ter that the number of "too thin" childrenhad dropped to half of what their original(base-line) survey showed.

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No doubt the enthusiasm of these "junior health workers," and the invol-vement of the parents and grandparents of the undernourished childrenin focusing on their nutritional needs, had much to do with the favorableresults. The process is empowering and unifying for the whole commu-nity.

H.THE IMPACT OF DISCOVERY BASED AND CHILD-TO-CHILD TECHNIQUES

Clearly the health and nutrition needs of infants in impoverished, margi-nalized families will not be resolved by the willing assistance of a group ofschoolchildren. To do away with hunger, the underlying "social determi-nants" of health (cultural, economic, and political) must also be collectively

If the child measures... feed her at least...

GREEN

YELLOW

RED

She is WELL FED

She is SO-SO

She is TOO THIN

MEALSA DAY3

MEALSA DAY4MEALSA DAY5

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addressed. But the long-term transfor-mative potential of the Child-to-Child ap-proach to education should not be un-derestimated. Its influence both on thechildren involved and on the schoolsystem can be far-reaching. Introducingempowering service-related activities likethese into public education, beginningwith primary school – can, little by little,help make schooling more relevant tothe daily needs and lives of the childrenin their homes and villages. This can bea big step forward toward transforming"compulsory education" from an oppres-sive tool of social control into an open-ended adventure in learning that challen-ges children to think for themselves andwork together for the common good.

Many schoolteachers are at first quiteskeptical about Child-to-Child. The open-ended, bottom-up methodology strikesthem as undisciplined, chaotic, and dis-respectful to authority. Because it challen-ges children to decide things for themsel-ves, it scares the teachers. But many ofthese same skeptical, fearful teachers,once they begin to take part in the Child-to-Child activities, become just as excitedas the children. They discover that througha two-way learning process, where ever-yone's thoughts and ideas are valued, theycan gain the pupils' respect, not as bossesbut as friends. This new more amiable,more equal interaction somehow strikesa deep, convivial chord in their nature.And the educational process becomesmore friendly and natural for everyone.

With Child-to-Child and discovery-basededucation, children will begin to questionthe injustices, inequities, and shortsigh-tedness of our current social order. Inthis way education can become transfor-

mative for the children, their teachers,their schools and our societies.

The world we are handing down to ouryoung is a time bomb with a short fuse!If our children are to have a chance atdefusing this deadly bomb, they will needto look in a radically new and differentway at how we human beings relate toone another and to our endangered pla-net. Starting now, concerned young peo-ple need to throw off the chains of thedominant world view ... to question whatthey're taught and told ... to resist themyopic dictates of the ruling class ... toexpose the fallacy in what is miscalled"progress" and "development." Theyneed to critique the failings of our currentsocial order, and embark on a revolutio-nary, evidence-based quest for the healthand well-being of all.

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SE PUEDE HALLAR INFORMACIÓN Y EJEMPLOS DE NIÑO A NIÑO EN ESTOS TRESLIBROS DE DAVID WERNER:

l NADA SOBRE NOSOTROS SIN NOSOTROSl APRENDIENDO A PROMOVER SALUDl EL NIÑO CAMPESINO DESHABILITADO

ACCESIBLES COMPLETAMENTE EN:

www.healthwrights.org

V. ConCLusIon: WHere do

We go froM Here?

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A. THE CHALLENGE

Today, in the 21st Century, we live in a different and more endan-gered world than in the past. In some areas we may have seen im-provements, as with women's rights and gay rights (at least insome places). But in terms of wealth and power, humanity has be-come even more polarized. And environmentally -- with the loomingtsunami of global warming -- we are on the brink of disaster. Yetthe world's rulers appear to be blind to the horrendous dangerstheir megalomania is creating. North-American neo-imperialismknows no bounds -- even as the great dinosaur sinks into thequicksand of its own greed.

But some healthy things are happening, too. One encouraging ad-vance of this new century, led by Latin America, is the growingnumber of populations who, after enduring centuries of colonialand then neocolonial oppression, have begun to rise up en masseand say, "Ya basta!" (Enough!) People who for generations havebeen brainwashed to obey their masters and suffer in silence havefinally begun to shake off the shackles of institutionalized exploita-tion. What a huge step forward for Latin America! And soon, let ushope, for humanity!

But this momentum for change did not just happen in a vacuum.The groundwork was built over decades, through grassroots effortsof common people working together to resolve their basic needs,to improve their health, and finally to demand their basic right toself-determination. Beyond a doubt, the web of community-basedhealth programs, and the movements that grew out of it, have pla-yed a seminal role that helped mobilizing the groundswell forchange. Key to this was the concientización (awareness-raising)that helped trigger this empowering process: what Paulo Freirecalled "Pedagogy of Liberation," -- and we health activists call "Edu-cation for Change."

When we talk about improvements in the health of an entire nation,Cuba is exemplary. In solidarity with the poor peoples of the worldthrough their creativity in finding solutions to feed its people, andits excellent universal health care – for its advances in medicineand biotechnology – Cuba inspires.

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We are no longer so naive as when webegan. We know that the economic elitewill oppose anything that considers theirprofits less important than the wellbeingof all people. The world's giant, profit-hungry corporations have more wealthand decision-making power than mostof the world's nations, or than the UnitedNations, so we face a daunting task. Ob-viously we cannot look to those in powerto initiate the changes that are needed.

The push needs to come from below. Itis time for the world's people -- like thepeople in a growing number of LatinAmerican countries -- to stand up andcry, "Ya basta!" But for such a globalgroundswell of solidarity to come about,a groundswell of organized action is ne-eded. The People's Health Movement,at regional and global level, is alreadyplaying a critical role in this process.

But many of us are getting older. Wehave struggled, sacrificed and learned.We have done some things well. Wehave also made mistakes. Now we mustlook to young people to learn from bothour successes and our failures, and tocarry the struggle forward. That is why I

have given such emphasis to the impor-tance of a liberating educational appro-ach. Only though such an egalitarian.open-ended approach to learning do we,Homo sapiens, have a hope of living inbalance with our own intrinsically lovingnature and the inseparably diverse natureof the Universe.

B.“SUMAK KAUSAY” AND THEDREAM OF HEALTH FOR ALL

For too long, the dominant concepts of"development" and "progress" havebeen tethered to the capitalist paradigmof unlimited growth through the exploi-tation of people and the unbridled ex-traction of resources from the environ-ment. But this acquisitive approach todevelopment -- as if the Earth belongedto us, rather than us to it -- is now retur-ning like a boomerang.

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Ultimately, what our common struggle comes down to, in LatinAmerica and worldwide, in the not-too-distant future, is Health forAll or Health for No One.

I would like to reemphasize that today, on our endangered planet,when we speak of Health for All, "All" doesn't mean only us (moreor less) hairless apes. It means Health for ALL, in the most inclusivesense. We humans are one small but disruptive part of an astoun-ding universe where everything is interwoven as a vibrant livingwhole. We are a thread in the web of life on this beautiful planet: aparticipant in the ecological balance of all biologic and non-biologicthings: a part of Earth, Air, Fire, and Water, of Warm and Cold, of Yinand Yang, of which the mysterious cosmos is composed. Unlessand until we learn to live in balance and compassion with one ano-ther, and with our critically-endangered ecosystem -- local and global-- health for any of us will remain a short-lived dream.

This larger vision of unity and empathy for all is, of course, the es-sence of the ancient Ecuadorian concept of Sumak Kausay or "BuenVivir" (good living). The indigenous peoples of the Americas livedmore in balance with the environment, and have a more intuitiveunderstanding of the Oneness-of-which-we-are-all-part, than domost of us in our morbidly overdeveloped consumer society today.It is heartening that Ecuador, with its long history of indigenous wis-dom, built into its new Constitution, in 2008, a declaration of theuniversal rights not only of all people, but of the natural world. Thisaffirmation of the "Rights of Nature" as part of "holistic living," orSumak Kuasay, is a large but humble step forward toward the visionwe share for the Health and Rights of ALL.

Sí, ¡ToDoS noSoTroS JunToS!

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l Werner, David, Where There Is No Doctor, 1974, Macmillan Press, London; HesperianHealth Guides, Berkeley, California, http://hesperian.org/books-and-resources/

lWerner, David, Helping Health Workers Learn, 1982. Hesperian Health Guides, Berkeley,California,

l Werner, David. "The Village Health Worker: Lackey or Liberator" 1977; World HealthForum. 1981. http://whqlibdoc.who.int/whf/1981/vol2-no1/WHF_1981_2%281%-29_%28p46-68%29.pdf Or see: https://healthwrights.org/content/articles/lackey_or_li-berator.htm

l Werner, David and Sanders, David, Questioning the Solution: The Politics of PrimaryHealth Care and Child Survival. HealthWrights. Palo Alto, California, 1997. https://he-althwrights.org/index.php?option=com_content&view=article&id=208:ques-solu&ca-tid=85

l Paulo Freire, Pedagogy of the Oppressed, 1968. Barnes and Noble

l International People's Health Council, Werner, D., Zuniga, M, et a. Health Care inSocieties in Transition,1993, CISAS, Nicaragua

l CISAS - Centro de Información y Servicios de Asesoría en Salud (Centro de Informacióny Servicios de Asesoría en Salud); http://www.cisas.org.ni/

l HealthWrights website: www.healthwrights.org

l Politics of Health website: www.politicsofhealth.org

l AKAP, Queson City, Filipinas. "Primary Health Care and Human Dignity" 1982. Reporton Philippine/Latin American CBHC Exchange in August 1981

lWerner, David B. "Good News – and not so good news – from Bangladesh" Newsletterfrom the Sierra Madre # 70, Dec., 2012,http://healthwrights.org/index.php?option=com_content&view=article&id=241?

l Schoolboys of Barbiana, Letter to a Teacher. 1967. Vintage Books, Vancouver, Washington.Online as pdf: http://www.swaraj.org/shikshantar/LTAT_Final.pdf

l Wikipedia. "Rights to Nature" (Sumak Kausay or Buen Vivir = "Good Life" in Kichwa) http://en.wikipedia.org/wiki/Rights_of_Nature#Ecuador_Development

REFERENCES

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