by David WernerSalud y Bien Vivir"
(Multicultural Encounter for Health and Living Well)
at the first international assembly of
The People's Health Movement--Latin America
Cuenca, Ecuador, October 7-11, 2013
A. The struggle for health is a struggle for social justice
In our ongoing struggle for the Health and Rights of All, now in the 21st Century, what can we learn from the hey-day of the Community Based Primary Health Care in Latin America during the last half of the 20th Century?
I would suggest we can learn a lot ... including things that can help ground us in our current strategies of organized action for change. As an aging activist from those challenging times, I would like to share with you some stories and lessons about the role that village health promoters and their grassroots networks played in the pursuit of health and social justice in those days.
The period from the 1960s into the 1990s was an exciting if difficult time, one of valiant popular action for equal rights and the common good. These grassroots actions in many countries were countered by the ruling classes with brutal repression including torture, disappearances, and other violations of human rights and international law. But for all the suffering and setbacks, this was a time when some very positive, deep-seated changes took place. A number of heavy-handed dictatorships were ousted, in spite of -- and in part because of -- their overt or covert support from the United States. In many ways, the struggles from the '60s into the '90s laid the foundation for the more recent, dramatic shifts toward representative government and "Power by the People" that have been emerging in the 21st Century. Indeed this new millennium has promise of becoming the "post-neocolonial era" where marginalized peoples collectively stand up to both national and foreign potentates, and cry out, "Ya basta!" (Enough is enough!)
What we all need to remember and learn from is the key role that Community Based Health Care played -- and can still play -- in this liberating, bottom-up Struggle for Health for All. The People's Health Movement in Latin America, as an outgrowth of this popular struggle of the previous century, can indeed be informed and inspired by its early history.
B. The politicization of Primary Health Care in Latin America
Beginning in the late 1950s, in various parts of Latin America, small nongovernment health programs began to crop up in the poorest, most underserved rural areas and urban slums. It was a time when a large percentage of the population lived in extreme poverty, with little or no public support. The political system was largely "neocolonial," in so far as the foreign powers that had colonized and dominated the indigenous peoples of the Americas had been replaced by internal power structures that were equally oppressive, though still beholden to their northern masters. Some of these countries were clearly dictatorships. Others had the trappings of democracy, but the huge gap in privilege and power between the "haves" (los de arriba) and "have-nots" (los de abajo) left the poor largely voiceless and powerless. This downtrodden majority lived in abject poverty. Hunger was common and the classic diseases of under-nutrition and poor sanitation took a huge tool. Child and maternal mortality was distressingly high. Formal health services were out of reach of the poor because of distance and cost. And ironically, professional medical care -- for those folks who could get it -- was another big cause of sickness and death. Its high price increased hunger and lowered resistance to disease. Even today, in many countries, the outrageously high cost of doctors and medicine is still a leading cause that drives low-income, working families into absolute destitution and total dependence.
This combination of social injustice, poverty-related ills, and minimal public services at this time led to the "spontaneous generation" of numerous small, non-government community health programs, which sprung up in the 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 socially idealistic but politically naive -- at least initially. They had little understanding of the cruel-pecking order and systemic injustice that kept the poor campesinos voiceless, disempowered, and economically enslaved. On the contrary, these well-meaning outsiders (and I was one of them) tended to see the devastating health problems in biomedical terms, to be corrected primarily with biomedical treatment. But through working closely with the people, we gradually became aware of the underlying social determinants of health In these marginalized and underserved and largely indigenous communities, the backlog of needs was vast. The small makeshift clinics were soon swamped as people poured in from farther and farther away. Short of staff, the programs began to train local people -- including traditional healers and birth attendants -- as front-line health workers or "promotores de salud." Because these promotores were selected by and served their own communities, most were very dedicated. They tended to work for the people, not the money.
As the community-based, primary care programs evolved and became more participatory, the promotores and villagers began to discuss and analyze the underlying causes of the health-related problems. Then they began to organize to overcome their common problems, at least at the local level. Out of these collective efforts grew informal organizations: of mothers, landless farmers, day laborers, share-croppers, even street children and youth, all seeking a louder voice in the decisions that affected their health and their lives. In this way, many informal community-based programs evolved from a focus on curative care, to preventive measures, and finally to socio-political action.
As such community initiatives began to mobilize people to address the root causes of ill health, often they were seen as threats by the local power structure: landlords, public authorities, loan sharks, medical professionals, and others whose routine exploitation of the poor contributed to hunger and poor health. As a result, many of the non-government programs that were first welcomed as inoffensive charities were eventually blacklisted by the local authorities and in time by national governments -- especially those that were most oppressive and distant from the poor. The last thing they wanted to see was peasant communities organizing to defend their health and their rights. Increasingly harsh rules and obstacles were imposed for such grassroots initiatives, and in some countries health workers or participating midwives were arrested -- or worse.
As a result, in countries where organized opposition was on the rise, many persecuted health workers went underground and joined resistance movements. With their valuable health and organization skills, some become leaders in the growing liberation struggles against tyrannical rule.
In this way, grassroots Community Based Health Care in Latin America came to play a key role in the mobilization of marginalized people in the struggles that contributed to the emerging process of genuine democratization in Latin America ... and beyond.
Let me give you a few examples with which I am more familiar:
This is only the beginning of this fascinating and informative presentation. To see a copy of it as it was put into a booklet:
Click here for the English version
And here for the Spanish version