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Globalization Of Health From Below: Lessons for Medical Education and Health Care Dr. Ravi Narayan Community Health Advisor, CHC Bangalore Outgoing Coordinator People’s Health Movement, Global Secretariat 30 th November 2007 THE LATE H.M.PATEL MEMORIAL LECTURE Charutar Arogya Mandal, Gujarat

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Globalization Of Health From Below: 1971- When the story began!

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Globalization Of Health From Below: Inspiration: 1 Refugee Camp 1971 What sort of health Professional would you like to be? Drugs/ vaccines? Social vaccines?

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Globalization Of Health From Below: Inspiration: 2 UK 1973 W hat sort of researcher do you want to be?

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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. Globalization Of Health From Below: Inspiration: 3 WHO 1978 The Primary Health Care Movement towards Health for All by 2000AD

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Globalization Of Health From Below: Inspiration: 3 WHO 1978 The Alma Ata Declaration <ul><li>“ 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………. </li></ul><ul><li>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. </li></ul><ul><li>Primary health care is the key to attaining this target as part of development in the spirit of social justice”. </li></ul>

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Globalization Of Health From Below: Inspiration: 4 India - 1981 Health for All – The Prescription of ICMR and ICSSR <ul><li>“ A Mass movement to </li></ul><ul><li>Reduce Poverty inequality and spread education. </li></ul><ul><li>Organise poor and underprivileged to fight for their basic rights </li></ul><ul><li>Move away from the counter productive Western model of health care and replace it by an alternative based in the community …..” </li></ul>

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Globalization Of Health From Below Diagnosis -1 RECOGNISING HEALTH CRISIS- 1990’S <ul><li> ECONOMIC CHANGES AFFECTING PEOPLES HEALTH AND ACCESS TO HEALTH / SOCIAL SERVICES </li></ul><ul><li>POVERTY AND HUNGER INCREASING </li></ul><ul><li>GAPS BETWEEN RICH AND POOR NATIONS WIDENED; INEQUALITIES WITHIN COUNTRIES INCREASING </li></ul><ul><li>LARGE PROPORTION LACK ACCESS TO BASIC NEEDS (FOOD, WATER, SANITATION, LAND, SHELTER, EDUCATION) </li></ul><ul><li>PLANETARY RESOURCES BEING RAPIDLY DEPLETED </li></ul>

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Globalization Of Health From Below Diagnosis -2 RECOGNISING HEALTH CRISIS- 1990’S <ul><li> UPSURGE OF CONFLICTS / VIOLENCE </li></ul><ul><li>WORLDS RESOURCES INCREASINGLY CONCENTRATED IN HANDS OF FEW WHO STRIVE TO MAXIMISE THEIR PROFIT </li></ul><ul><li>NEW ECONOMIC / POLITICAL POLICIES AFFECTING LIVES, LIVELIHOODS, HEALTH AND WELL BEING OF PEOPLES IN SOUTH AND NORTH </li></ul><ul><li>PUBLIC SERVICES DETERIORATING, UNEVENLY DISTRIBUTED AND INAPPROPRIATE </li></ul><ul><li>PRIVATIZATION UNDERMINING ACCESS AND EQUITY PRINCIPLES </li></ul><ul><li>Source-PHA 2000 </li></ul>

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<ul><li>“ A retreat from the goal of national health and drug policies as a part of an overall social policy; </li></ul><ul><li>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; </li></ul><ul><li>The failure to promote participation and genuine involvement of communities in their own health development; </li></ul><ul><li>Reduced state responsibilities at all levels as a </li></ul><ul><li>consequence of wide spread - and usually </li></ul><ul><li>inequitable - privatization of health policies; </li></ul><ul><li>A narrow, top-down, technology - oriented view of health” </li></ul>Globalization Of Health From Below Diagnosis -3 RECOGNISING THE CRISIS IN INDIA-1990’S

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Globalization Of Health From Below Diagnosis -4 Less Food No job No water What are the people saying?

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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 Diagnosis-5 Impact of the crisis – 1990’s

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“ Massive poverty and obscene inequality are social evils, like slavery and apartheid” - Mandela, 2005 Globalization Of Health From Below Diagnosis-6

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Globalization Of Health From Below Diagnosis-7 Increasing Poverty and inequality ….. The greatest obstacle to Health for All and the Millennium Development Goals Poverty / Inequality

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Globalization Of Health From Below Action Research -1 Recognizing and Evolving a new Paradigm-1 <ul><li>Chapter -21 </li></ul><ul><li>Educational Approaches in Tuberculosis Control: Building on the Social Paradigm </li></ul><ul><li>…… .T.Narayan; R. Narayan. </li></ul><ul><li>Recognizing the social paradigm </li></ul><ul><li>Widening the Educational Frame work </li></ul><ul><li>From Bio Medicine to Socio Epidemiology </li></ul><ul><li>Educational initiatives : from Content to process </li></ul><ul><li>An alternative strategy – From DOTS to COTS </li></ul>

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Globalization Of Health From Below Action Research -2 Researching levels of analysis and solutions Source: Narayan T.,1998 More just international relations, trade relations etc. Contraindications and inequalities in socio-economic and political systems at international, national and local levels Basic cause (international problem) Land reforms, social movements towards a more egalitarian society Poverty / deprivation, unequal access to resources Underlying cause (symptom of inequitable relations) Development and welfare – income generation / housing Under nutrition/ low resistance, poor housing, low income / poor purchasing capacity Immediate cause BCG, case finding and domiciliary chemotherapy Infectious disease / germ theory Surface phenomenon (medical and public health problem) Solutions / Control strategies for tuberculosis Casual understanding of tuberculosis Levels of analysis of tuberculosis

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Globalization Of Health From Below Action Research -3 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”

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Globalization Of Health From Below Action Research -4 Understanding the Obstacles to Health for All <ul><li>What Globalization Means for Peoples Health. </li></ul><ul><li>Whatever happened to Health for All by 2000AD </li></ul><ul><li>Making life worth living </li></ul><ul><li>A World Where We Matter </li></ul><ul><li>Confronting Commercialization in Health Care! </li></ul>

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Globalization Of Health From Below Action-1 Health and Social Networks come together in 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

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

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Globalization Of Health From Below Action- 3 Mobilizing Health activists for the movement

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Globalization Of Health From Below Action-4 Jan Swasthya Sabha, Kolkata 2000 <ul><li>Over 2000 participants in 5 peoples health trains </li></ul><ul><li>Mobilization across 19 </li></ul><ul><li>states </li></ul><ul><li>Adopted 20 point Indian </li></ul><ul><li>People’s Charter </li></ul><ul><li>Launched the Jan </li></ul><ul><li>Swasthya Abhiyan, </li></ul><ul><li>campaigning for </li></ul><ul><li>Health for All Now </li></ul><ul><li>Health as a Fundamental </li></ul><ul><li>Human Right </li></ul>

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

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Globalization Of Health From Below Action-6 The People’s Charter for Health “ Health is a social, economic and political issue and above all a fundamental human right.”

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Globalization Of Health From Below Action-7 The 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.”

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Globalization Of Health From Below Action-8 The People’s Charter for Health “ 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.”

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Globalization Of Health From Below Action-9 Vision of PEOPLE’S CHARTER <ul><li>A World with equity, ecologically sustainable development and peace </li></ul><ul><li>A world in which a healthy life for all is a reality </li></ul><ul><li>A world that respects, appreciates and celebrates all life and diversity </li></ul><ul><li>A world which enables flowering of peoples talents and abilities to enrich each other </li></ul><ul><li>A world in which people’s voices guide the decisions that shape our lives </li></ul>

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Globalization Of Health From Below Action-10 PEOPLE’S CHARTER FOR HEALTH PRINCIPLES 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 <ul><li>ACTION AT ALL LEVELS TO TACKLE CRISIS </li></ul><ul><ul><li>Individual </li></ul></ul><ul><ul><li>Community </li></ul></ul><ul><ul><li>National </li></ul></ul><ul><ul><li>Regional </li></ul></ul><ul><ul><li>Global </li></ul></ul>

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Globalization Of Health From Below Action-11 PHM INDIA <ul><li>Dialogue with political parties </li></ul><ul><li>State and national health policy Dialogue </li></ul><ul><li>Right to Health Care Campaign with National </li></ul><ul><li>Human Rights Commission </li></ul><ul><li>People’s Rural Health Watch </li></ul><ul><li>Support to Campaigns: </li></ul><ul><li>Right to Food; Against Water Privatization; Access to Essential Medicines- Patents/TRIPS; Environment issues; Gender; HIV / AIDS; Women’s Health </li></ul>

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People’s health tribunals in India Dialogue with policy makers on behalf of the movement <ul><li>A Peoples Court or Civil Court </li></ul><ul><li>A panel of judges and experts is setup by the National Human Rights Commission </li></ul><ul><li>The senior-most State health officials act as respondents </li></ul>Globalization Of Health From Below Action-12

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People’s health tribunals in India Dialogue with policy makers on behalf of the movement Globalization Of Health From Below Action-13 <ul><li>People and activists present case studies and survey reports </li></ul><ul><li>Proceedings are videotaped and documented </li></ul><ul><li>Attended by members of the community / civil society </li></ul>

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Globalization Of Health From Below Action-14 Campaign for Access to Essential Medicines <ul><li>State Essential Drug List and Therapeutic Guidelines </li></ul><ul><li>Critique of Amendment of Indian Patent Act 1970 </li></ul><ul><li>National Meeting on Pharmaceutical Policy – 2005 </li></ul><ul><li>Campaign against Novartis – Gleevec </li></ul><ul><li>Data Exclusivity </li></ul>

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Globalization Of Health From Below Action-15 Right to Health Movement

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Globalization Of Health From Below Action-16 Campaigns on Gender Issues <ul><li>Campaign Against Sex Selective Abortion or Female Foeticide – 2001 onwards </li></ul><ul><li>Campaign on Violence against Women as a Public Health Challenge – 2000 onwards </li></ul><ul><li>Women’s Access to Primary Health Care - 2003 </li></ul><ul><li>People’s Tribunal on Population Policies – 2004 </li></ul><ul><li>Gender and Power Issues in Medical Education </li></ul><ul><li>Women’s Health Charter - 2007 </li></ul>

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Globalization Of Health From Below Action-17 Involving the Socially excluded and marginalized

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Globalization Of Health From Below Action-18 Interaction with National With National Rural Health Mission (NRHM) <ul><li>Members of Task Force and Advisory Committee </li></ul><ul><li>Shifted the missions focus from Demography to Public Health </li></ul><ul><li>Community Monitoring </li></ul><ul><li>People Rural Health Watch </li></ul><ul><li>ASHA Mentoring Group </li></ul>

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Globalization Of Health From Below Global Action-1 Peoples voices at international level World Social Forum, Porto Allegre Brazil

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Globalization Of Health From Below Global Action-2 The Mumbai Declaration-2004 “ Pressure the World Bank and the IMF to acknowledge their culpability in the health crisis.” End 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.”

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Globalization Of Health From Below Global Action-3 People’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.”

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Publications Globalization Of Health From Below Global Action-4

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Globalization Of Health From Below Global Action-5 Globalizing solidarity from over 80 countries at the Second People’s Health Assembly, Cuenca Ecuador

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Globalization Of Health From Below Global Action-6 “ 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 Declaration 2005

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Globalization Of Health From Below Global Action-7 Global Health Watch - I Alternative World Health Report 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 29 th July at PHA 2

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Globalization Of Health From Below Global Action-8 Advocacy with WHO to renew Primary Health Care 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

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Globalization Of Health From Below System Engagement-1 Academics 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

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Globalization Of Health From Below System Engagement-1 Academics 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

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Globalization Of Health From Below System Engagement-2 Conceptual significance of PHM – globalisation 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

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Globalization Of Health From Below System Engagement-3 Conceptual significance of PHM – globalisation 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

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Globalization Of Health From Below System Engagement-4 “ 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 )

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Globalization Of Health From Below System Engagement-5 PUBLIC 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….

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Globalization Of Health From Below System Engagement-6 Public 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”

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Globalization Of Health From Below System Engagement-7 Advising main stream Journals eg: BMJ

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Globalization Of Health From Below System Engagement-8 Participating in Global Forum for Health Research where concept of paradigm shift and social vaccine being discussed

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Globalization Of Health From Below Challenges ahead 1 THE NEED FOR A PARADIGM SHIFT Psycho- social, cultural, economic, political, ecological Physical / pathological Dimensions Type of service Research Socio – epidemiology Social determinants Health Systems Social Policy Molecular biology Pharmaco – therapeutics Clinical Epidemiology Enabling / Empowering Autonomy Building Providing/ Dependence creating / Social marketing Community as active Participant Patient as passive beneficiary Link with people Education and social processes Drugs / vaccines Technology Community Individual Focus Participatory social/ community research Biomedical deterministic research Approach

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Superficial Only clinical? Only epidemiological? Only techno-managerial? Or deeper? Social? Economic? Cultural? Political? Structural? Globalization Of Health From Below Challenges ahead 2 Understanding the social determinants of health

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Globalization Of Health From Below Challenges ahead 3 Understanding the social determinants of health Disease? Illhealth? Or tackling social determinants like Poverty? Gender bias? Conflict? Stigma? Social exclusion? What is the focus of action?

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Globalization Of Health From Below Challenges ahead 4 Dialogue with Academics and Researchers

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Globalization Of Health From Below Challenges ahead 5 Promoting Research and Action in the New Paradigm

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Globalization Of Health From Below Challenges ahead 6 Towards a Social Vaccine – Challenges for Research

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Globalization Of Health From Below Challenges ahead 7 Meeting the challenges of today in India <ul><li>Farmers Suicides </li></ul><ul><li>Childhood Malnutrition </li></ul><ul><li>Communalism & Social Conflicts </li></ul><ul><li>Non Communicable Disease Epidemic </li></ul><ul><li>Resurgence / return of the vector borne diseases </li></ul><ul><li>Development related displacement </li></ul><ul><li>Pollution impacted communities </li></ul><ul><li>And ……….. </li></ul><ul><li>We need new paradigms and new social vaccines </li></ul><ul><li>Are we ready for the challenge </li></ul>

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Globalization Of Health From Below Challenges ahead 7 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

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Thank you www.phmovement.org

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Health for All, Now ! JOIN US THANK YOU

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For further information visit www.sochara.org www.phm-india.org www.phmovement.org www.ghwatch.org www.iphcglobal.org