Transcript Community Health – Christian Contribution to Primary

Community Health –
Christian Contribution to
Primary Health Care
Jack Bryant
CCIH Conference
Bishop Claggett Center, Buckeystown, MD
May 24, 2008
Agenda
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Reflection on Carl Taylor’s contributions.
How I became involved in this field – and it
changed my life!
The Quest for Health and Wholeness.
Christian Medical Commission—its founding
and response to WHO’s call for new
perspectives on health and well-being. 1970s
Primary Health Care – CMC contribution to
WHO’s new approach to Health and
Development. 1970s
Agenda
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Alma-Ata 1978 – International Conference on
Primary Health Care -- Event of Major Global
Importance
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Post Alma-Ata – 30 years of events, positive
and negative.
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Buenos Aires Conference, WHO-PAHO, 2007,
Renewal of Alma-Ata Commitments.
Pre-Alma Ata
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Challenge to International Agencies – article
written by Carl Taylor, 1975.
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Five Principles Underlying the New
International Style
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Ten Guidelines for Practical Implementation
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Conclusion: What kind of world do we want?
I close with a quality of life question that is
intermeshed with many basic moral and
philosophical issues. Are affluent countries
coming to the point where we will have to
choose what not to have and what not to do,
rather than continuing to monopolize a
disproportionate share of the world’s goods?
Pre-Alma Ata
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I close with a quotation from Martin Luther
King: “Through your scientific genius, you
have made a world a neighborhood but you
have as yet failed to employ your moral and
spiritual genius to make of it a brotherhood.”
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This is our Challenge!
Pre-Alma Ata – the Churches
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JB, then working in Thailand, called by Philip
Potter, World Council of Churches, to meet in
Copenhagen, 1967. John Karefa Smart,
important leader in Sierra Leon, also
present.
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Concern for instability of 1200 mission
hospitals in newly independent countries.
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What to do about those hospitals?
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Response: Wrong Question. Concern should
reach beyond hospitals to focus on how to
provide health care for the people, including
those who cannot reach the hospitals.
Pre-Alma Ata – the Churches
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Potter: Who knows how to provide such
health care for all the people?
Bryant: There are many who are working at
it. Let us seek their advice.
Potter: Yes. Let us bring them together.
Result: The founding of the Christian Medical
Commission.
The CMC became a major player in the
thinking and actions related to Alma Ata and
PHC. Bryant and Taylor early participants.
The Quest for Health and
Wholeness
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The Quest for Health and Wholeness, 1981.
James C. McGilvray, Director, Christian
Medical Commission – CMC. Brilliant,
thoughtful, committed leadership.
This fine book tells the story of events, and
inquiries into Christian perspectives, values,
and concerns that led to the founding of the
Christian Medical Commission.
German Institute for Medical Missions,
Tubingen, Germany -- continuous support of
the CMC, before and after its founding
Two meetings of critical importance to the
founding and support of CMC were
Tubingen I, 1964 and Tubingen II, 1967.
The Quest for Health and
Wholeness
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This book describes only a segment of this
QUEST. Its content is determined by the
experience of a group of people variously
related to the promotion of health and/or to
the practice of medicine who were drawn
together at various times by their Christian
commitment and desire to understand the
relationship between health, wholeness and
salvation and what this understanding,
however tentative, would say to the
Churches’ involvement in medical mission.
The Quest
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For some, the search for the meaning of
health was first prompted by an involvement
in evaluating the contribution of Western
medicine to the health care of populations in
lesser developed countries.
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It began with surveys of church-related
medical programs in several African and
Asian countries in order to measure their
effectiveness in meeting the health needs of
the people and, also, their appropriateness
as expressions of a Christian ministry of
healing.
The Quest
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From the surveys, it was found that the
churches had concentrated their efforts on
building and operating hospital and clinicbased curative services, which had limited
impact on the problems.
They were, basically, repair facilities which
did little if anything to remove the causes of
sickness or to promote and maintain health.
The Quest
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While they were necessary components of a
medical care system, their relevance was
diminished because of the absence or
paucity of other components of a medical
care system, such as public health
measures, primary health facilities, etc.,
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and their operating costs were so high,
relative to the resources, that the possibility
of meeting more basic health needs was
precluded.
The Quest
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Moreover, these church-related institutions,
together with all the other available facilities
of Western medicine, were reaching only
20% of the populations in these countries,
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so that 80%, and these were usually the
poorest and most needy, were deprived of
services other than traditional forms of
healing when these were available.
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The obvious disparity between those served
and those deprived of medical services
challenged the priority, long practiced in
Western medicine, of individual care on a
one-to-one basis.
The Quest
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Human life has a social dimension as well as
a personal core, and while medicine must be
person-oriented rather than disease-oriented
it can never neglect the social relationships
and demands which shape the person.
This led to the formulation of community
medicine – a system designed to bring the
benefits of medical care in an acceptable
manner to as many as possible.
This was later amended to correct the
imbalanced relationship between
professionals and those who bore the
burden of sickness, so that the latter fully
participated in the development of the
system of care and in the therapy itself.
The Quest
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David Jenkins, Professor and Head,
Department of Religious Studies, University
of Leeds.
Foreword to the Quest for Health and
Wholeness
If, therefore, we have faith, hope and
compassion we are launched on a Quest.
This is a quest for new ways of responding
practically and hopefully to the continuing
evidences and experiences of human
sickness and disease.
The Quest
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If one is a Christian or a sympathiser who is
seeking for a fresh vision of what
Christianity, at its heart, has pointed to or
might point to, then the quest is at the same
time a quest for a renewed and effective
understanding of the presence of God and of
what He offers through a re-shaped and reinvigorated fellowship or church.
The Quest
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Thus it will be found that the account which
follows naturally contains a number of
strands. There is a search for effective
contemporary ways of understanding and
sharing the Christian Gospel. There is a
search for new forms of expressing and
being the Church in local service and in
worldwide witness.
The Quest
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The book which follows is an account of how
some people, who are committed to
Christianity and committed to the practice of
medicine, have tried to face contemporary
realities which call both into question.
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The questions which are posed, the
criticisms which have to be faced, and the
problems which have to be solved, emerge
as the account proceeds.
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All that needs to be pointed out in a
Foreword is that the search described began
from, and continues to be sustained by,
convictions about the truth inherent in the
Christian Gospel.
Dr. Robert Lambourne
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From his reports emerged disturbing picture
of the manner in which modern care was at
odds with the quest for health & wholeness.
The growth of medical specialization has
tended to break down the patient into
pathological parts so that less and less is he
regarded or treated as a whole patient.
Technology and research…dehumanize what
should be a very personal approach. The
results of a battery of tests becomes more
important than the relationship of persons in
a therapeutic encounter. Translated into
institutional form, the hospital becomes a
factory for repair of things rather than as a
hospice for the care of souls.
Perspectives on Health and
Healing
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J. Bryant, Chairman of CMC, addressed the
question of “health care and justice”.
He applied the notions of “entitlement”,
“natural rights”, and “positive rights”, and
developed some tentative principles:’
Whatever health services are available
should be equally available to all. Departures
from that equality of distribution are
permissible only if those worst off are made
better off.
Perspectives on Health and
Healing
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There should be a floor or minimum of health
services for all.
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Resources above the floor should be
distributed according to need.
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In those instances where health care
resources are non-divisible or necessarily
uneven, their distribution should be of
advantage to the least favored.
Tubingen I
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1963 – Division of World Mission and
Evangelism of the World Council of
Churches and the Commission on World
Mission of the Lutheran World Federation –
decided to sponsor a consultation which
would address itself to these issues.
In a proposal for such a consultation these
bodies reiterated their firm belief that there is
a Christian understanding of the meaning of
health and the means of healing which forms
an essential part of the contribution of a
Christian medical service.
God’s purpose for the redemption of man as
proclaimed in the Gospel of Jesus Christ is
contained in acts that restore man to the
wholeness of his life.
Tubingen I
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Man is not himself aware of the real nature of
the sickness that infects him – body, mind,
spirit. God in human form brings new being
to man, restores him to fellowship with
himself, offers him hope in the world, and
calls him to a service in the world which he
as redeemed and healed man can do in
gratitude for God’s supreme act of salvation.
So, the purpose of the consultation was set.
It was to explore this claim to uniqueness in
the Christian understanding of health and
healing.
It also had a pragmatic objective to explore
that need for new missionary strategy and
planning.
Tubingen I
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The Findings clearly indicate the unanimous
opinion of the participants that the Church
does have a specific task in the field of
health which arises from its place in the
whole Christian belief about God’s plan of
salvation for mankind.
Whether in the desperate squalor of
overpopulated and underdeveloped areas, or
in the spiritual wasteland of affluent
societies, it is a sign of God’s victory and a
summons to his service.
The participants expressed their regret that
there was so little evidence in theological
education of concern for or explicit teaching
about the Christian understanding of healing.
Tubingen II
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1967, again held at the German Institute for
Medical Mission, Tubingen, Germany.
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An introduction attempted to state the
problems and pressures generated by
contemporary health and medical services –
that while, in varying degrees, man lives
longer than he used to; his stay in the
hospital is shorter and he has a much greater
hope of recovery from diseases which were
once considered fatal; in the process, he has
been reduced to an impersonal object.
Because of the focus on his localized
pathology, he tends to lose his identity and
individual uniqueness.
Tubingen II
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Fortunately, the Christian faith is not
dependent on its institutions or
professionals. The gospel still proclaims a
God of love and justice who overwhelms all
technologies and offers a quality of life
which alone can provide that health and
wholeness (salvation) which is God’s intent
for his people.
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And for those who cannot fathom the
mysteries of theological formulations, there
still remains the invitation of Christ himself.
Tubingen II
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Come, enter and possess the kingdom that
has been ready for you since the world was
made. For when I was hungry you gave me
food; when thirsty, you gave me drink; when
I was a stranger you took me into your home,
when naked you clothed me; when I was ill
you came to my help, when in prison you
visited me…I tell you this, anything you did
for one of my brothers here, however
humble, you did for me. (St. Matth. 25L3436m 40)
Critical Community-Based
Experiences.
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1972 – WHO/UNICEF Joint Committee on
Health Policy prepared a document on
“Alternative Approaches to Meeting the
Basic Health Needs of Populations in
Developing Countries”.
WHO called for reports of promising
projects.
CMC responded accordingly and identified
three projects, each of which offered
important lessons among alternative
approaches.
Critical Community-Based
Experiences.
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First, 1967, McGilvray “discovered” a project
in Indonesia run by Dr. and Mrs. (Dr.)
Gunawan Nugroho. Initiated 1963, and
featured such innovations as goat and
chicken farming to increase the income
available to the poorest members of the
community and the creation of a health fund
that aimed at providing inexpensive
treatment so that anyone who was sick could
afford to seek medical care.
Critical Community-Based
Experiences.
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In addition to curative and preventive
services, a community health program
should “place greater emphasis on activities
that increase the potential of man to live
healthily. Educational activities aimed at the
dissemination of lucid information about
health and nutrition, the spread of disease
and its consequences, the responsibility of a
patient towards the general community and
his own milieu, family health, and family
planning are the basis of a community health
program.
Critical Community-Based
Experiences.
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Second – also run by a husband-wife medical
team, Mabelle and Rajanikant Arole.
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Their project developed in Jamkhed India
was supported by the CMC. They described
in 1970 how their intitial attempts at
providing curative services “had done little
for the general health of the community
around us”.
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They left India to go to Johns Hopkins
University to study public health where they
were directly influenced by the works of
several members of the CMC, particularly
Carl Taylor.
Critical Community-Based
Experiences.
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The Jamkhed Project, as conceived at Johns
Hopkins, aimed to establish a viable and
effective health care system that involved the
community in “decision-making”, was
“planned at the grass roots”, used local
resources “to solve local health problems,”
and provided “total care, not fragmented
care.”
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Raj Arole presented the Jamkhed Project to
the 1972 CMC annual meeting. Since then,
the Jamkhed Project has become an
international training center. (Connie Gates,
here today, has a major role)
Critical Community-Based
Experiences.
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Third, Carroll Behrhorst directed the
Chimaltenango development project in
Guatemala, the third project to be included in
Health by the People. (Ken Newell, WHO).
The use of community health promoters was
one of the major features of this project.
Selected by the communities and often with
a limited education, promoters were trained
“to recognize and alleviate common medical
problems.”
Critical Community-Based
Experiences.
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But treating diseases ranked 7th on the list of
priorities as judged by the local Indian
population. Their list was headed by: 1.
Social and economic injustice. 2. Land
tenure. 3. Agricultural production and
marketing, and 4. Population control,
leading Behrhorst to conclude:
The truly successful public health program
among the rural poor must tackle basic
problems of economic and political
development. This by no means indicates
that program leaders should plunge into
controversial national issues or ally
themselves with specific political
movements.
Critical Community-Based
Experiences.
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A program must be detached from factional
politics if it is to respond to the people
without power. Yet, there are levels below
those of national politics where the people
can learn to control their own lives through
politics and economics. A cooperative is a
good example, since it responds to financial
need and builds local leadership.
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Behrhost presented his project at the 1973
CMC annual meeting.
PHC: WHO’s New Approach to
Health Development
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The relationship between the CMC and WHO
has been portrayed in terms of an anecdotal
story involving Halfdan Mahler, WHO
Director General, and Nita Barrow, Deputy
Director of the CMC.
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When invited in 1974 to introduce the CMC’s
approach to comprehensive health care to
the staff of WHO, she responded, “But this is
like David and Goliath,” to which Mahler
replied, “Yes, but I am a parson’s son and I
know what David did to Goliath.”
PHC: WHO’s New Approach to
Health Development
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The most significant result of this
cooperation between the two organizations –
WHO and CMC -- was the formulation of the
principles of Primary Health Care, which
were absorbed by the leadership of WHO.
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The Executive Board of WHO identified
issues of critical importance:
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a) shape PHC around the life patterns of the
population;
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b) involve the local population;
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c) place a maximum reliance on available
community resources;
PHC: WHO’s New Approach to
Health Development
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d) provide for an integrated approach of
preventive, curative and promotive services
for both the community and the individual;
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e) provide for all interventions to be
undertaken “at the most peripheral
practicable level of the health services by the
worker most simply trained for this activity”;
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f) provide for other echelons of services to
be designed in support of the needs of the
peripheral level; and
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g) be “fully integrated with other sectors
involved in community development.”
PHC: WHO’s New Approach to
Health Development
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Four general courses of national action were
outlined with the expectation that each
country would respond to the need in a
unique manner. These were:
1) the development of a new tier of PHC;
2) the rapid expansion of existing health
services with priority being given to PHC;
3) the reorientation of existing health
services so as to establish a unified
approach to PHC;
4) making maximum use of ongoing
community activities, especially developmental ones, for the promotion of PHC.
PHC: WHO’s New Approach to
Health Development
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The CMC, along with other NGOs with similar
policies, provided those responsible for PHC
within WHO with an exciting outlet of
creative activity, one that deserves to be
revisited by those today who are concerned
with community health development.
Reflections on the CMC
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There is no doubting the contributions of the
CMC:
 Its focus on health care systems in need of
extensive change.
 Its bringing together persons from both
diverse religious groups and Churches,
with WHO, to focus on health care needs
in poor countries.
 Its provision of examples of communitybased health care, particularly applicable
to less developed countries.
 Its subsequent reflections on fresh
perspectives of both theology and health.
Alma Ata -- 1978
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One of the great events in the history of
public health.
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U.S. Delegation – Julius Richmond, Surgeon
General; Carl Taylor, Jack Bryant, Peter Bell,
Ted Kennedy.
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Influenced the professional lives of us all.
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Bryant was then a staff person with
President Jimmy Carter, and served on the
Executive Board of WHO, thereby immersed
in global health issues.
After Alma-Ata
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There were many events following Alma-Ata
that tell us of the positive and negative
sequences to the Alma-Ata Story
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There were anniversary meetings – 10 years,
15 years, 20 years, 25 years – after Alma Ata,
and I attended each of them.
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Here is a brief example.
10th Anniversary of Alma-Ata,
RIGA, USSR, 1988
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Reflecting on a decade of action and inaction
related to PHC. It was clear that not enough
was being done, and there was an insistent
call for new forms of analysis, partnerships
and new mechanisms of action.
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Mahler: “We must have an obsession, a
moral obsession, about the least developed
countries. They are missing out totally in the
development process. It is development
gone wrong.”
WHO’s Role
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In a December 2003 article in the Lancet,
WHO Director General, Lee wrote:
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A crucial part of justice in human relations is
promotion of equitable access to healthenabling conditions. The Alma-Ata goal of
Heath for All was right. So were the basic
principles of primary health care: equitable
access, community participation, and
intersectoral approaches to health
improvement. These principles must be
adapted to today’s context.
After Alma-Ata
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In this complex world, there have been
numerous perspectives on health and
development, some positive and consistent
with Alma-Ata, others reaching into other
sectors and values.
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Here is a listing of the major perspectives
and processes of the 30 years since AlmaAta
Changing Perspectives on PHC
and Development
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Social Determinants of Health
Selective PHC
Neoliberalism
Globalization
Commission on Macroeconomics and Health
Millennium Development Goals
PAHO – values, principles, elements of PHC
WHO’s new Director General –
Dr. Margaret Chan
Alma-Ata and Primary Health
Care – An Evolving Story
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2005 -- International Encyclopedia for Public
Health, Elsevier Press, London.
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Asked: J. Bryant, Julius Richmond, to write a
chapter on Alma-Ata for the Encyclopedia.
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Agreed -- The work began in 2005. Wonderful
to go back to the 1960s and 70s, reviewing
the CMC story and related events.
Onward with the Chapter
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Bryant visited WHO-Geneva, 2007.
Meetings with Halfdan Mahler, Mirta Roses
Periago, staff of Margaret Chan.
There was interest in the Alma-Ata Chapter.
Meanwhile, WHO/PAHO were responding to
Margaret Chan’s commitment to Primary
Health Care…planned a Conference on PHC
and the MDGs, Buenos Aires, August, 2007
Bryant, do join us for this important event!
And he did!
Buenos Aires 30/15
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From Alma Ata to the Millennium Declaration.
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International Conference on Health for
Development: “Rights, Facts and Realities”
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Buenos Aires 30-15 Declaration “Towards a
Health Strategy for Equity, Based on Primary
Health Care”
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Honorary President: Dr. Halfdan Mahler
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Honored Participant: Dr. Margaret Chan
Bryant Chapter
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Elsevier Press agreed to inclusion in the
Chapter of an Addendum, based on Buenos
Aires.
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Bryant formulated the Addendum, based
mainly on personal comments made by
prominent members of the Conference
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There follows remarks made by familiar
persons in leadership roles. It is so
interesting to hear what they are saying – in
their own words!
Halfdan Mahler
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I see amazing inequity patterns in health
indicators throughout our whole miserable
world. I am not talking about the first, second
or third world. I am talking about one single
world, the only one that we have to share and
take care of.
Equity, understood as assurance of
satisfaction of basic needs in terms of health
as well as social and economic needs,
especially in connection with vulnerable
groups, is for me the fundamental objective
of every development.
Ravi Narayan – People’s Health
Movement
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I represent the people who are being left out!
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People come to us with a cough, and we give
them cough syrup. But, if we listen, they tell
us stories of poverty, injustice, exploitation.
Is the cough syrup enough?
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Health for All needs a new paradigm.
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We have to move from top-down, vertical
globalization, to a people-led globalization
involving everybody from bottom-up.
Michael Marmot – Social
Determinants of Health
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There should be a partnership between
social determinants of health and primary
health care – they need each other.
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High quality academic work is important, but
we want to see academic work translated
into action.
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We want to create a global movement that
places fair health, health equity, at the head
and heart of social policy.
Margaret Chan
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The topics explored in this conference
(Buenos Aires, 2007) embrace some of the
most pressing issues in public health today
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Obviously, if we want better health to work
as a poverty reduction strategy, we must
reach the poor. And we must do it with
appropriate high quality care.
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What role can PHC play in this quest?
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How can we overcome major barriers, such
as weak health systems, inadequate
numbers of health care staff, and the
challenge of financing care for impoverished
people?
Margaret Chan
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Apart from its passionate call for equity and
social justice, Health for All also launched a
political struggle on at least three fronts.
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First, it sought to make health part of the
political agenda for development, to upgrade
the profile of health and increase its prestige.
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Second, it sought to broaden the approach to
health, to move away from the narrow
medical model of curative care. It
acknowledged the power of prevention. And
it recognized that health has multiple
determinants, including some in sectors
other than health.
Margaret Chan
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Third, the Declaration of Alma Ata argued
that better health for populations should go
hand in hand in a mutually supportive way,
with better economic and social productivity.
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These, then, were some of the political
struggles surrounding a movement launched
in the name of social justice and for the good
of our common humanity.
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Our common humanity gives us reason to
care. It is why we must act with urgency in
the face of an emergency. It is also why we
have so much to gain, in the name of social
justice.
Mirta Roses Periago
Towards an Equity Based
Comprehensive Health Care
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The Legacy of Alma-Ata. The social and
health policy itinerary from 1978 to 2007
shows us that PHC has had an enormous
influence on public policies, on the
configuration of health systems, and on the
thinking and actions of health workers.
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We can and should build a new vision of PHC
in health systems in order to make them
capable of achieving health for all. That is to
say -- health systems based on PHC.
Mirta Roses Periago
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Three points remain clear for all of us:
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1. We do not need weak, selective, or
incomplete PHC that, as we say, is like a
poor man’s blanket that when stretched to
cover one side leaves the other side
uncovered. We want something that covers
us all, not a PHC with basic packages only
for the poor, or for rural areas, or for
marginal areas.
Mirta Roses Periago
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2. We need and we want PHC that has equity,
universality, solidarity and social
participation, that reflects a rich encounter of
knowledge, that is intersectoral, that makes it
possible for us to successfully address the
social determinants of health, and that
affirms and ensures the right to health care.
Mirta Roses Periago
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3. We need and we want the PHC of Alma Ata
firmly rooted in the passion and commitment
of 1978 and with the projection and capacity
to transform current health systems,
because we need them urgently, and
because they are indispensable to the
viability and sustainability of human society
in the 21st century, when we will all have to
share the same and only planet.
Reflections – Buenos Aires
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It is such a pleasure to listen to the words of
today’s global leadership in the health
sector, to catch the subtleties of their
remarks, knowing that they are based on
conviction, commitment, and genuine
capacities for effective action.
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Thank you Halfdan, Ravi, Michael, Margaret
and Mirta.
Reflections -- CMC
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So interesting to see how much of the CMC
thinking has persisted in global health
perspectives.
And, through the comments of these
individual leaders in the health sector, such
thinking is directed at the differential needs
of people in diverse settings and
circumstances.
Thank you, CMC!