Content: Essay. Overview: Essay looking at the work of the health advocate David Werner in reducing morbidity and mortality caused by easily preventable diseases within many isolated villages and communities. Please Note - This essay is purely academic and I will not accept legal responsibility for any information, interpretations or options contained herein. - Feel free to utilise, critique, print or reference any of this content :)

1. Advocacy Written Assignment (2016; edited 2017)
Mark R O’Donovan; 113320506
Health issue – Today there is still high morbidity and mortality caused by easily
preventable diseases within many isolated villages and communities.
Advocate – David Bradford Werner
Public health significance of the issue
Globally there is widespread inequality; with our poorest communities being enslaved by the cruel
grips of disease, deficiency, corruption, and ignorance. These communities are not only deprived of
the very building blocks of health and wellbeing, but are often leached of the very knowledge and
resources necessary to change this.
– “Health care is not only everyone’s right, but everyone’s responsibility” (Werner et al. 2015,
p.Introduction).
Health and wellbeing are generally regarded as fundamental moral rights and responsibilities that
enable people to live fulfilling lives and achieve their full potentials. It has routinely been declared a
human right under legal and political documentation such as UN Universal Declaration of Human
Rights (1948); International Covenant on Economic, Social and Cultural Rights; International
Convention on the Elimination of All Forms of Racial Discrimination (1965); American Declaration of
the Rights and Duties of Man; Protocol of San Salvador; Vienna Declaration; Convention on the
Elimination of All Forms of Discrimination against Women (1979); Convention on the Rights of the
Child (1989); and in 109 of the world’s 193 National Constitutions. (Kinney 2001).
– How do we define health and wellbeing?
However while we may believe people are entitled to health; health itself is an extremely complex
phenomenon deeply rooted in philosophical understandings (Larson 1999, Nordenfelt 2007), ethical
considerations (Nuffield Council on Bioethics 2007), and cultural contexts (Napier et al. 2014); an
area the WHO is currently studying in their new “Cultural Contexts of Health” project (WHO 2016a).
For these reasons health has been instantiated as a “receding mirage” in the work of biologist Rene
Dubos 1960 (cited in Larson 1999), and studies have consistently shown that health possesses
different connotations for different people (Collins et al. 2006). However despite the complex nature
of health itself we can still estimate its status using agreed upon health indicator measures; with the
WHO having derived a list of 100 core health indicators for 2015 (WHO 2016c).
Please Note
- This essay is purely academic and I will not
accept legal responsibility for any information,
interpretations or options contained herein.
- Feel free to utilise, critique, print or reference
any of this content 

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Scientific basis for public health action
Looking at the health indicator of life expectancy at birth, in 2015 we can see there are major global
inequalities (Figure 1). With a 16.8 year difference between the WHO African and European Regions
(WHO 2016b); and a 25.5 year difference between Sierra Leone and Japan (WHO 2016e).
Including morbidity as well, we can look at the years of “healthy” life lost in 2015, using the IHME’s
(2016) Disability Adjusted Life Years (DALYs). These estimates again illustrate significant global
disparities (Figure 2); varying per 100,000 people between 15,000 DALYs in Kuwait and 92,000 DALYs
in Lesotho.
– Think globally, act locally…
While inequality exists in the global context if we look closer we will find that inequality and health
divides do not just exist between national geographic spaces but also within them; in communities,
villages, houses, and people’s lives. These internal divides can in fact be overlooked by national
averages. For example here in Ireland where we have a high life expectancy overall, members of the
traveller community have average life expectancies that are 15.1 years lower for men and 11.5 years
lower for women (Abdalla et al. 2010).
Figure 1: Global life expectancies at birth (both sexes) in 2015 (WHO 2016e)
Figure 2: Global DALYs for all causes (all ages, both sexes)per 100,000 in 2015 (IHME 2016)

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– Working with communities and community healthcare
Thus it is important to identify and work with communities that have poorer health outcomes.
However while there is the greatest need/responsibility to work with these individuals they actually
often suffer from a shortage of medical professionals, and many maintain tradition understandings
of health and wellbeing that are of varying degrees of effectiveness (WHO 2002, Werner et al. 2015).
– Health professional shortages
In fact looking at the latest WHO data on skilled health professions there is a global shortage (Figure
3), with the majority concentrated in financially advantaged regions which logically have less need
for their services. In the most extreme identified case Guinea has a rate of only 1.4 health
professionals per 10,000 people i.e. 1 health professional for every 7,143 people (WHO 2016d).
Older needs-based estimates (Scheffler et al. 2008) predicted there to be global surplus of physicians
in 2015, but shortages on a Regional basis (Figure 4). GNP is estimated to explain 49% of the
distribution of physicians and 40% of the distribution of nurses (Wharrad and Robinson 1999). All
this information is very well encapsulated in a striking WHO graphic from 2006 (Figure 5).
Figure 3: Skilled health professionals density and distribution from 2005-2013 (WHO 2016d)
Figure 4: Physician shortages in 2015 based on demand and need models
(Scheffler et al. 2008)
Figure 5: Distribution of health workers by level of health expenditure and
burden of disease for each WHO region (WHO 2006)

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The public health advocate involved
David Werner born in 1934 Ohio, and a biologist by
training, sought to address these problems through
community based health care, social empowerment
and advocacy (Werner 2016a, Werner 2016b).
Throughout his career he has earned 9 awards and
fellowships including the WHO’s first international
award for Education in Primary Health Care 1985,
the MacArthur Fellowship “genius award” June
1991-1996, and the Christopherson Award for
International Child Health 1992 (Werner 2016b).
The advocacy strategy, tactics and/or framework
His approach is one of promoting human rights and empowering local people to manage their own
health wherever possible; while working holistically with local culture, agriculture, construction etc.
(Werner et al. 2015). He believes that “Ordinary people provided with clear, simple information can
prevent and treat most common health problems in their own homes—earlier, cheaper, and often
better than can doctors” (Werner et al. 2015, p.Introduction) and aims to freely disperse health
knowledge amongst these people. This approach is similar to the training of non-physician clinicians
in 47 sub-Saharan African countries and the Barefoot doctors in China which were both a successful
response to a shortage of medical physicians (Mullan and Frehywot 2008). He also heavily endorses
values seen in modern community development approaches (Lynam 2007) trying to help people
reach the top of Arnstein’s ladder of citizen participation (Figure 6).
– Where There Is No Doctor (Werner et al. 2015).
Werner’s most well-known health promotion action
was the publication of his first full book “Donde no
hay doctor” (Where there is no doctor) in 1977 while
working in rural Mexico. This book is a self-help
guide for the prevention of disease and the
management of common health problems. It is
simply written with many illustrations drawn by
Werner in order to make it accessible to both lay
people and health care workers, and it has since
been produced in over 90 languages (Werner 2016a).
Since this publication he has written 6 other books
including “Disabled Village Children: A Guide for
Community Health Workers, Rehabilitation Workers, and Families”; “Nothing About Us Without Us:
Developing Innovative Technologies For, By and With Disabled Persons”; and “Karate Kids: What We
Need to Know about AIDS” (Werner 2016b).
David B. Werner – photo from his blog (Werner 2016a)
Figure 6: Ladder of citizen participation (Arnstein 1969).

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As well as full books he has also written extensively in other places such as articles, papers, and book
chapters, totalling 92 items according to his CV (Werner 2016b). While Werner’s main focus is in
teaching and ethical integration of new practices he was naturally faced with much financial
opposition when working in areas that could not afford the most basic medical supplies and
interventions. He has done much to change this and I think he has acted as a social entrepreneur as
defined by the Ashoka organisation’s 5 qualities of a social entrepreneur - a new idea, creativity,
entrepreneurial quality, social impact of the idea, and ethical fiber (Ashoka [No date]).
– A New Idea
Werner wanted to provide free self-help medical info to the world, and founded the Hesperian
Foundation (re-named Hesperian Health Guides in 2011) to promote the distribution of his written
materials with an open copyright policy (Hesperian Health Guides 2016b). Today they have more
than 20 publications with most being free to download on their website in addition to the
purchasable hardcopies (Hesperian Health Guides 2016c). In 1993 he co-founded another similar
organisation called HealthWrights which he has directed since (Werner 2016b).
– Creativity
He has been very creative in terms of making information accessible to
different cultures and in his explanatory illustrations and sketches
(Werner et al. 2015). Having studied Sumi-e-ga charcoal ink brush
painting in Kyoto Japan in 1961, he is a strong believer in using imagery
to promote and explain ideas (Werner et al. 2015, Werner 2016a).
– Entrepreneurial Quality
He is also very committed to his work, still being actively involved with
the HealthWrights organisation, and over the years he has manged to
get funding for his work from 20 different organisations including the
Kellogg Foundation, OXFAM, and UNICEF (Werner 2016b).
The impact of the public health advocacy work on this issue
– Social Impact of the Idea
Publications by Hesperian Health Guides are produced in 80 different languages and have reached
nearly every country and region of the world (Figure 7). They are widely used by “Peace Corps
volunteers, missionaries, teachers, health educators and community organizers to improve health
around the world”, and are thought to have saved millions of lives (Hesperian Health Guides 2016a).
There is also the contributions of the HealthWrights organisation that he founded in 1993 with
similar aims (Werner 2016c, Werner 2016b).
Art by David Werner from his blog (Werner 2016a)

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– Ethical Fiber
Werner’s writings have always promoted ethical cultural integration and working with traditional
medicine and practices where they are causing no harm, and is extremely dedicated to the
empowerment and rights of others (Werner et al. 2015). However there have been multiple
unconfirmed reports of him being sexually involved with boys and young men which led to him
resigning from Hesperian Health Guides in 1993 and his subsequent founding of HealthWrights
organisation later that year (Hesperian Health Guides 1994).
One example of media coverage of the issue/advocate
As far as the media is concerned Werner’s contribution goes mostly unnoticed but has played an
instrumental role behind the scenes; his influence globally affecting the way many volunteers do
their work, especially in relation to easily preventable diseases and doctor shortages as well as
respect of cultural identities and practices.
In summary his influence has led to freely accessible, widely used health guides that have massively
influenced preventable disease rates through community development, empowerment, and
people’s knowledge of health in areas deprived of the most customary health demand of the
developed world – a doctor.
Figure 7: Impact and coverage of Hesperian Health Guides (Hesperian Health Guides 2016a)

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