globalization of health from below: lessons for medical education and health care

Globalization Of Health From Globalization Of Health From Below:Below:

Lessons for Medical Education and Health Lessons for Medical Education and Health CareCare

Dr. Ravi NarayanDr. Ravi NarayanCommunity Health Advisor, CHC BangaloreCommunity Health Advisor, CHC Bangalore

Outgoing Coordinator People’s Health Movement, Global Outgoing Coordinator People’s Health Movement, Global Secretariat Secretariat

3030thth November 2007 November 2007

THE LATE H.M.PATEL MEMORIAL LECTURETHE LATE H.M.PATEL MEMORIAL LECTURE

Charutar Arogya Mandal, GujaratCharutar Arogya Mandal, Gujarat

Globalization Of Health From Below:Globalization Of Health From Below:

1971- When the story began!1971- When the story began!


Inspiration: 1 Refugee Camp 1971Inspiration: 1 Refugee Camp 1971

What sort of health Professional would you like to be?What sort of health Professional would you like to be?

Drugs/ vaccines?

Social vaccines?


Inspiration: 2 UK 1973Inspiration: 2 UK 1973

WWhat sort of researcher do you want to be?hat sort of researcher do you want to be?

Alma Ata, 1978

The International Conference on Primary Health Care calls for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world by the year 2000.


Inspiration: 3 WHO 1978Inspiration: 3 WHO 1978

The Primary Health Care Movement towards Health for All by The Primary Health Care Movement towards Health for All by

2000AD2000AD


Inspiration: 3 WHO 1978Inspiration: 3 WHO 1978

The Alma Ata DeclarationThe Alma Ata Declaration

• “The conference strongly reaffirms that health is a state of complete physical, mental, and social well being……. A fundamental human right ………… and the attainment of the highest possible level of health is a most important world wide social goal……….

•Governments have a responsibility for the health of their people which can be fullfilled only by provision of adequate health and social measures…… A main social target of the whole world community should be the attainment of all the people of the world by the year 2000 of the level of health care that will permit …… a socially and economically productive life.

• Primary health care is the key to attaining this target as part of development in the spirit of social justice”.


Inspiration: 4 India - 1981 Inspiration: 4 India - 1981

Health for All – The Prescription of ICMR and ICSSR Health for All – The Prescription of ICMR and ICSSR

“A Mass movement to

•Reduce Poverty inequality and spread education.

•Organise poor and underprivileged to fight for their basic rights

•Move away from the counter productive Western model of health care and replace it by an alternative based in the community …..”

Globalization Of Health From BelowGlobalization Of Health From Below Diagnosis -1Diagnosis -1

RECOGNISING HEALTH CRISIS- 1990’SRECOGNISING HEALTH CRISIS- 1990’S • ECONOMIC CHANGES AFFECTING PEOPLES HEALTH

AND ACCESS TO HEALTH / SOCIAL SERVICES

• POVERTY AND HUNGER INCREASING

• GAPS BETWEEN RICH AND POOR NATIONS WIDENED; INEQUALITIES WITHIN COUNTRIES INCREASING

• LARGE PROPORTION LACK ACCESS TO BASIC NEEDS (FOOD, WATER, SANITATION, LAND, SHELTER, EDUCATION)

• PLANETARY RESOURCES BEING RAPIDLY DEPLETED


RECOGNISING HEALTH CRISIS- 1990’SRECOGNISING HEALTH CRISIS- 1990’S• UPSURGE OF CONFLICTS / VIOLENCE

• WORLDS RESOURCES INCREASINGLY CONCENTRATED IN HANDS OF FEW WHO STRIVE TO MAXIMISE THEIR PROFIT

• NEW ECONOMIC / POLITICAL POLICIES AFFECTING LIVES, LIVELIHOODS, HEALTH AND WELL BEING OF PEOPLES IN SOUTH AND NORTH

• PUBLIC SERVICES DETERIORATING, UNEVENLY DISTRIBUTED AND INAPPROPRIATE

• PRIVATIZATION UNDERMINING ACCESS AND EQUITY PRINCIPLES

Source-PHA 2000

•“ A retreat from the goal of national health and drug policies as a part of an overall social policy;

•A lack of insight into the inter-sectoral nature of health problems and the failure to make health a priority in all sectors of society;

•The failure to promote participation and genuine involvement of communities in their own health development;

•Reduced state responsibilities at all levels as a consequence of wide spread - and usually inequitable - privatization of health policies;

•A narrow, top-down, technology - oriented view of health”


RECOGNISING THE CRISIS IN INDIA-1990’S RECOGNISING THE CRISIS IN INDIA-1990’S

Globalization Of Health From Below Globalization Of Health From Below Diagnosis -4Diagnosis -4

Less Food No job

No water

What are the people What are the people saying?saying?

Corporate led globalization, Neo-liberal economic

reforms, Negative macro-policies

Corporate led globalization, Neo-liberal economic

reforms, Negative macro-policies

Adversely affect the social majority,

nationally & globally

Livelihoods,Incomes,

Food security,Increased conflict,War and violence,Access to water,

Access to health care,Environmental degradation,

Globalization Of Health From Below Globalization Of Health From Below Diagnosis-5Diagnosis-5

Impact of the crisis – 1990’sImpact of the crisis – 1990’s

“Massive poverty and obscene inequality are

social evils, like slavery and apartheid”

- Mandela, 2005

“Massive poverty and obscene inequality are

social evils, like slavery and apartheid”

- Mandela, 2005



Increasing Poverty and inequality ….. The Increasing Poverty and inequality ….. The greatest obstacle to Health for All and the greatest obstacle to Health for All and the Millennium Development GoalsMillennium Development Goals

Poverty / Inequality

Globalization Of Health From Below Globalization Of Health From Below Action Research -Action Research -1 1

Recognizing and Evolving a new Paradigm-1Recognizing and Evolving a new Paradigm-1

Chapter -21

Educational Approaches in Tuberculosis Control: Building on the Social Paradigm

…….T.Narayan; R. Narayan.

1. Recognizing the social paradigm

2. Widening the Educational Frame work

3. From Bio Medicine to Socio Epidemiology

4. Educational initiatives : from Content to process

5. An alternative strategy – From DOTS to COTS

Globalization Of Health From Below Globalization Of Health From Below Action Research -2Action Research -2

Researching levels of analysis and solutionsResearching levels of analysis and solutions

Levels of analysis of tuberculosis

Casual understanding of tuberculosis

Solutions / Control strategies for tuberculosis

Surface phenomenon (medical and public health problem)

Infectious disease / germ theory

BCG, case finding and domiciliary chemotherapy

Immediate cause Under nutrition/ low resistance, poor housing, low income / poor purchasing capacity

Development and welfare – income generation / housing

Underlying cause (symptom of inequitable relations)

Poverty / deprivation, unequal access to resources

Land reforms, social movements towards a more egalitarian society

Basic cause (international problem)

Contraindications and inequalities in socio-economic and political systems at international, national and local levels

More just international relations, trade relations etc.

Source: Narayan T.,1998


Presented to Independent Commission on Health in India(A CHC Report 1998) - Agenda for Change

“Strong countervailing movement initiated by health and development professionals and activists, consumer and people’s organizations (over 20 networks) to bring health care and medical education and their right orientation high on the political agenda of the country and to ensure that the health policy choices are led by people’s health needs, not market factors”


Understanding the Obstacles to Health for All

1.What Globalization Means for Peoples Health.

2.Whatever happened to Health for All by 2000AD

3.Making life worth living

4.A World Where We Matter

5.Confronting Commercialization in Health Care!

Globalization Of Health From BelowGlobalization Of Health From Below Action-1Action-1

Health and Social Networks come togetherHealth and Social Networks come togetherin 2000 ADin 2000 AD

Asian Community Health Action Network (ACHAN)All India People’s Science Network (AIPSN)All India Democratic Women’s Association (AIDWA); All India Drug Action Network (AIDAN); Association for Indian Development, India (AID – India); Bharat Gyan Vigyan Samiti (BGVS); Breast Feeding Promotion Network of India (BFPNI); Catholic Health Association of India (CHAI);Christian Medical Association of India (CMAI); Federation of Medical Representatives and Sales Association of India (FMRAI); Forum for Crèche and Child Care Services (FORCES); Joint Women’s Program (JWP); Medico Friends Circle (MFC); National Alliance of People’s Movements (NAPM); National Alliance of Women’s Organizations (NAWO); National Federation of Indian Women (NFIW); Society for Community Health Awareness, Research and Action (SOCHARA); Voluntary Health Association of India (VHAI).

National Resource Groups in the NCC are: SATHI – CEHAT, Pune; Centre for Social Medicine and Community Health, Jawaharlal Nehru University, Delhi; Community Health Cell (CHC), Bangalore; SAMA, Resource Group for Women and Health, Delhi; Health Watch, UP - Bihar

Globalization Of Health From BelowGlobalization Of Health From Below Action-2Action-2 Preparing Campaign Materials for Health Preparing Campaign Materials for Health

MobilizationMobilization

Globalization Of Health From Below Globalization Of Health From Below Action- 3Action- 3

Mobilizing Health activists for the Mobilizing Health activists for the movementmovement

Over 2000 participants in 5 peoples health trains Mobilization across 19

states Adopted 20 point Indian

People’s Charter Launched the Jan Swasthya Abhiyan, campaigning for

Health for All Now

Health as a Fundamental

Human Right

Globalization Of Health From BelowGlobalization Of Health From Below Action-4Action-4 Jan Swasthya Sabha, Kolkata 2000Jan Swasthya Sabha, Kolkata 2000

Globalization Of Health From BelowGlobalization Of Health From Below Action-5Action-5 The First Global People’s The First Global People’s

Health AssemblyHealth Assembly

In 2000 December 1454 health activists from 75 countries met in Savar, Bangladesh to discuss the challenge of attaining Health for All, Now! Over 250 Indian delegates attended

“Health is a social, economic and political issue and above all a fundamental human right.”


The People’s Charter for HealthThe People’s Charter for Health

“Health for all means that powerful interests have to be challenged, that globalisation has to be opposed, and that political and economic priorities have to be drastically changed.”



“Equity, ecologically-sustainable development and peace are at the heart of our vision of a better world. There are more than enough resources to achieve this vision.”



Globalization Of Health From BelowGlobalization Of Health From Below Action-9Action-9 Vision of PEOPLE’S CHARTERVision of PEOPLE’S CHARTER

A World with equity, ecologically sustainable development and peace

A world in which a healthy life for all is a reality

A world that respects, appreciates and celebrates all life and diversity

A world which enables flowering of peoples talents and abilities to enrich each other

A world in which people’s voices guide the decisions that shape our lives

Globalization Of Health From BelowGlobalization Of Health From Below Action-10Action-10 PEOPLE’S CHARTER FOR HEALTH PEOPLE’S CHARTER FOR HEALTH

PRINCIPLESPRINCIPLES

HEALTH IS FUNDAMENTAL HUMAN RIGHT

PRIMARY HEALTH CARE(1978 Alma Ata

Declaration)BASIS FOR POLICY

GOVERNMENTS FUNDAMENTAL

RESPONSIBILITY TO ENSURE ACCESS AND

QUALITY

PEOPLE AND PEOPLES ORGANISATIONS ESSENTIAL

TO FORMULATION, IMPLEMENTATION,

EVALUATION OF HEALTH PROGRAMMES

POLITICAL / ECONOMIC SOCIAL / ENVIRONMENT ARE PRIMARY DETERMINANTS OF HEALTH AND MUST GET TOP PRIORITY IN POLICY MAKING

ACTION AT ALL LEVELS TO TACKLE CRISIS

-Individual-Community-National-Regional-Global

Globalization Of Health From BelowGlobalization Of Health From Below Action-11Action-11 PHM INDIAPHM INDIA

• Dialogue with political parties

• State and national health policy Dialogue

• Right to Health Care Campaign with National Human Rights Commission

• People’s Rural Health Watch

• Support to Campaigns: Right to Food; Against Water Privatization; Access to Essential Medicines- Patents/TRIPS; Environment issues; Gender; HIV / AIDS; Women’s Health

• A Peoples Court or Civil Court

• A panel of judges and experts is setup by the National Human Rights Commission

• The senior-most State health officials act as respondents

Globalization Of Health From Below Globalization Of Health From Below Action-12Action-12

People’s health tribunals in IndiaPeople’s health tribunals in IndiaDialogue with policy makers on behalf of the Dialogue with policy makers on behalf of the

movementmovement

People’s health tribunals in IndiaPeople’s health tribunals in IndiaDialogue with policy makers on behalf of the Dialogue with policy makers on behalf of the

movementmovement


•People and activists present case studies and survey reports

•Proceedings are videotaped and documented

•Attended by members of the community / civil society

Globalization Of Health From BelowGlobalization Of Health From Below Action-14Action-14 Campaign for Access to Essential Campaign for Access to Essential

MedicinesMedicines

• State Essential Drug List and Therapeutic Guidelines

• Critique of Amendment of Indian Patent Act 1970

• National Meeting on Pharmaceutical Policy – 2005

• Campaign against Novartis – Gleevec• Data Exclusivity


Right to Health MovementRight to Health Movement

Globalization Of Health From BelowGlobalization Of Health From Below Action-16Action-16 Campaigns on Gender IssuesCampaigns on Gender Issues

• Campaign Against Sex Selective Abortion or Female Foeticide – 2001 onwards

• Campaign on Violence against Women as a Public Health Challenge – 2000 onwards

• Women’s Access to Primary Health Care - 2003

• People’s Tribunal on Population Policies – 2004

• Gender and Power Issues in Medical Education

• Women’s Health Charter - 2007


Involving the Socially excluded and marginalizedInvolving the Socially excluded and marginalized

Globalization Of Health From BelowGlobalization Of Health From Below Action-18Action-18 Interaction with National With National Rural Interaction with National With National Rural

Health Mission Health Mission (NRHM)(NRHM)

• Members of Task Force and Advisory Committee

• Shifted the missions focus from Demography to Public Health

• Community Monitoring• People Rural Health Watch• ASHA Mentoring Group

Globalization Of Health From BelowGlobalization Of Health From Below Global Action-1Global Action-1 Peoples voices at international Peoples voices at international

levellevelWorld Social Forum, Porto Allegre BrazilWorld Social Forum, Porto Allegre Brazil

Globalization Of Health From BelowGlobalization Of Health From Below Global Action-2Global Action-2

The Mumbai Declaration-2004The Mumbai Declaration-2004

“Pressure the World Bank and the IMF to acknowledge their culpability in the health crisis.”

End corporate-led globalisationEnd corporate-led globalisation

“Build the campaign for “No To TRIPS” in traditional systems of medicine and seeds.”

“Demand participation of people’s organisations, health workers, and farmers in policy-making for Access to Health.”

Globalization Of Health From BelowGlobalization Of Health From Below GlobalGlobal Action-3Action-3

People’s Charter on HIV/AIDS 2004People’s Charter on HIV/AIDS 2004

“HIV and AIDS is a development issue that calls for social and political action. It is also a public health issue that requires people-oriented health and medical interventions. Such responses require democracy, pro-people inter-sectoral policies, good governance, people’s participation and effective communication. They should be rooted in internationally accepted human rights and humanitarian norms.”

PublicationsPublications

Globalization Of Health From Below Globalization Of Health From Below Global Action-4Global Action-4


Globalizing solidarityGlobalizing solidarity from over 80 countries at the Second from over 80 countries at the Second

People’s Health Assembly, Cuenca People’s Health Assembly, Cuenca EcuadorEcuador


“The human right to health and health care must take precedence over the profits of corporations, especially the profiteering of pharmaceutical companies.”

“Unless it is massively reformed to operate democratically, the WTO must be dismantled as it is a major source of massive human rights violations and injustice and a key mechanism of corporate control of life on earth. “

The Cuenca The Cuenca Declaration Declaration

20052005

Collecting and interpreting evidence for policy change

125 academics/ researchers collate evidence and write contributory chapters for the first alternative world health report released on 29th July at PHA 2


Global Health Watch - IGlobal Health Watch - IAlternative World Health ReportAlternative World Health Report


Advocacy with Advocacy with WHO to renew Primary Health Care WHO to renew Primary Health Care and recognize social determinants of health and recognize social determinants of health

Recognizes the PHM role in evolving the new health and human rights approach to Primary Health Care – with the necessity of tackling the broader social and political determinants of health

Globalization Of Health From BelowGlobalization Of Health From Below SystemSystem Engagement-1Engagement-1

Academics recognize PHMAcademics recognize PHM“This movement is engaged in what amounts to ‘globalization from below’ as it builds support for its global ‘Health For All Now’ strategy, lobbies at the global level and mobilizes a grassroots based campaign to realize the vision and achieve the goals of the People’s Charter for Health.”

Richard Harris and Melinda Seid, 2004, The Globalization of Health

Globalization Of Health From BelowGlobalization Of Health From Below SystemSystem Engagement-Engagement-11

Academics recognize PHMAcademics recognize PHM“ The People’s Health Movement is clear evidence that the existing linkages between globalisation and health are contestable. The People’s Health Movement and the People’s Charter for Health provide a significant expression of alternatives ‘from below’ to the present globalisation, privatisation and comercialisation of health coming ‘from above.”

Richard Harris and Melinda Seid, 2004, The Globalization of Health


Conceptual significance of PHM – Conceptual significance of PHM – globalisation of health from belowglobalisation of health from below

“Development requires the removal of major sources of unfreedom; poverty as well as tyranny, poor economic opportunities as well as systematic social deprivation, neglect of public facilities as well as intolerance or over activity of repressive states .. The contemporary world denies elementary freedoms to vast numbers of people – perhaps even the majority of people.”

- Amartya Sen, 1999


Conceptual significance of PHM – Conceptual significance of PHM – globalisation of health from belowglobalisation of health from below

“…the immense power of TNC’s and the capacity of international financial and political dealings are no reason for ordinary people to surrender to economic fatalism…

These are all human institutions, they are subject to human will and they can be eliminated like other tyrannical institutions have been”

- Noam Chomsky, 2000


“ History suggests that such changes often demand radical forms of political mobilization and action, although history has not yet encountered such a demand on a global scale. No simple precedents exists but several forms of mobilization are already been pursued……….

The simultaneous rise of a global civil society movement pressing for political actions to shift the rules of contemporary globalization (People’s health movement et al 2005 )


PUBLIC HEALTH TEXT BOOK - UKPUBLIC HEALTH TEXT BOOK - UK

The Peoples Health Movement is an international network of organization and individuals that came together in 2000 to reignite the call for the Health for All, Now. The goal of PHM is to reestablish the health and equitable development as top priorities at local, national and international policy making, with comprehensive primary health care as the strategy to achieve this priorities…….

It is transnational network …… and a good example of an emerging player in global civil society… On a day today basis the secretariat in Bangalore …… puts forward strategic campaigning priorities….

Globalization Of Health From Below Globalization Of Health From Below SystemSystem Engagement-6Engagement-6

Public Health Text Book - SwedenPublic Health Text Book - Sweden

“A strong voice in the global health debate for free primary health care is the people’s health movement which in 2000, presented the Peoples Health Charter. The charter argues strongly for a publicly financed health services and for development policies that favours health…. This network presently led from Bangalore in India is a leading representative for NGO’s in the Global health debate. This global network is itself a new aspect of globalisation”

Globalization Of Health From Below Globalization Of Health From Below SystemSystem Engagement-Engagement-77

Advising main stream Journals eg: BMJAdvising main stream Journals eg: BMJ

Globalization Of Health From Below Globalization Of Health From Below SystemSystem Engagement-8Engagement-8Participating in Global Forum for Health Participating in Global Forum for Health

Research where concept of paradigm shift and Research where concept of paradigm shift and social vaccine being discussedsocial vaccine being discussed

Globalization Of Health From Below Globalization Of Health From Below Challenges ahead 1Challenges ahead 1

THE NEED FOR A PARADIGM SHIFTTHE NEED FOR A PARADIGM SHIFT

Approach Biomedical deterministic research

Participatory social/ community research

Focus Individual Community

Dimensions Physical / pathological Psycho- social, cultural, economic, political, ecological

Technology Drugs / vaccines Education and social processes

Type of service

Providing/ Dependence creating / Social marketing

Enabling / EmpoweringAutonomy Building

Link with people

Patient as passive beneficiary

Community as active Participant

Research Molecular biologyPharmaco – therapeuticsClinical Epidemiology

Socio – epidemiologySocial determinantsHealth SystemsSocial Policy

SuperficialOnly clinical?

Only epidemiological?Only techno-managerial?

Or deeper?Social?

Economic?Cultural?Political?

Structural?


Understanding the social determinants of health


Understanding the social determinants of Understanding the social determinants of health health

Disease?Illhealth?

Or tackling social determinants like

Poverty?Gender bias?

Conflict?Stigma?

Social exclusion?

What is the focus of action?

Globalization Of Health From BelowGlobalization Of Health From Below Challenges ahead 4Challenges ahead 4

Dialogue with Academics and ResearchersDialogue with Academics and Researchers

Globalization Of Health From BelowGlobalization Of Health From Below Challenges ahead 5Challenges ahead 5

Promoting Research and Action in the New Promoting Research and Action in the New ParadigmParadigm


Towards a Social Vaccine – Challenges for ResearchTowards a Social Vaccine – Challenges for Research


Meeting the challenges of Meeting the challenges of today in Indiatoday in India

• Farmers Suicides

•Childhood Malnutrition

•Communalism & Social Conflicts

•Non Communicable Disease Epidemic

•Resurgence / return of the vector borne diseases

•Development related displacement

•Pollution impacted communities

And ………..

We need new paradigms and new social vaccines

Are we ready for the challenge


In Conclusion In Conclusion We must relate our education to the life, needs and aspirations of the people and thereby make it the powerful instrument of social, economic and cultural transformation necessary for the realization of our goals…..

What we need is a system which encourages the spirit of experiment and creative skills …… (We) are not heros on a battle field ….. (We) are not powerful search lights exposing vast areas, but glow worms illuminating evenly a small area. …… I hope you will not have no hesitation in being good glow worms.

- From a convocation address -1978

Thank youThank you

www.phmovement.org

Health for All, Now !Health for All, Now !

JOIN US JOIN US THANK YOUTHANK YOU

For further information visit

www.sochara.orgwww.phm-india.org

www.phmovement.orgwww.ghwatch.org

www.iphcglobal.org

globalization of health from below: lessons for medical education and health care

Health & Medicine