Community Health Christian Contribution to Primary Health Care

1
Community Health Christian Contribution to
Primary Health Care

• Jack Bryant
• CCIH Conference
• Bishop Claggett Center, Buckeystown, MD
• May 24, 2008

2
Agenda

• Reflection on Carl Taylors contributions.
• How I became involved in this field and it
  changed my life!
• The Quest for Health and Wholeness.
• Christian Medical Commissionits founding and
  response to WHOs call for new perspectives on
  health and well-being. 1970s
• Primary Health Care CMC contribution to WHOs
  new approach to Health and Development. 1970s

3
Agenda

• Alma-Ata 1978 International Conference on
  Primary Health Care -- Event of Major Global
  Importance
• Post Alma-Ata 30 years of events, positive and
  negative.
• Buenos Aires Conference, WHO-PAHO, 2007, Renewal
  of Alma-Ata Commitments.

4
Pre-Alma Ata

• Challenge to International Agencies article
  written by Carl Taylor, 1975.
• Five Principles Underlying the New International
  Style
• Ten Guidelines for Practical Implementation
• 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 worlds goods?

5
Pre-Alma Ata

• 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.
• This is our Challenge!

6
Pre-Alma Ata the Churches

• 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.
• Concern for instability of 1200 mission hospitals
  in newly independent countries.
• What to do about those hospitals?
• 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.

7
Pre-Alma Ata the Churches

• 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.

8
The Quest for Health and Wholeness

• 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.

9
The Quest for Health and Wholeness

• 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.

10
The Quest

• 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.
• 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.

11
The Quest

• From the surveys, it was found that the churches
  had concentrated their efforts on building and
  operating hospital and clinic-based 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.

12
The Quest

• 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.,
• and their operating costs were so high, relative
  to the resources, that the possibility of meeting
  more basic health needs was precluded.

13
The Quest

• 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,
• 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.
• 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.

14
The Quest

• 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.

15
The Quest

• 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.

16
The Quest

• 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 re-invigorated fellowship or church.

17
The Quest

• 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.

18
The Quest

• 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.
• 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.
• 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.

19
Dr. Robert Lambourne

• 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 researchdehumanize 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.

20
Perspectives on Health and Healing

• 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.

21
Perspectives on Health and Healing

• There should be a floor or minimum of health
  services for all.
• Resources above the floor should be distributed
  according to need.
• In those instances where health care resources
  are non-divisible or necessarily uneven, their
  distribution should be of advantage to the least
  favored.

22
Tubingen I

• 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.
• Gods 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.

23
Tubingen I

• 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 Gods 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.

24
Tubingen I

• 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 Gods 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
  Gods 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.

25
Tubingen II

• 1967, again held at the German Institute for
  Medical Mission, Tubingen, Germany.
• 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.

26
Tubingen II

• 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 Gods intent for
  his people.
• And for those who cannot fathom the mysteries of
  theological formulations, there still remains the
  invitation of Christ himself.

27
Tubingen II

• 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 meI tell you this, anything you did for
  one of my brothers here, however humble, you did
  for me. (St. Matth. 25L34-36m 40)

28
Critical Community-Based Experiences.

• 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.

29
Critical Community-Based Experiences.

• 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.

30
Critical Community-Based Experiences.

• 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.

31
Critical Community-Based Experiences.

• Second also run by a husband-wife medical team,
  Mabelle and Rajanikant Arole.
• 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.
• 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.

32
Critical Community-Based Experiences.

• 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.
• 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)

33
Critical Community-Based Experiences.

• 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.

34
Critical Community-Based Experiences.

• 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.

35
Critical Community-Based Experiences.

• 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.
• Behrhost presented his project at the 1973 CMC
  annual meeting.

36
PHC WHOs New Approach to Health Development

• 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.
• When invited in 1974 to introduce the CMCs
  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 parsons son and I know what
  David did to Goliath.

37
PHC WHOs New Approach to Health Development

• 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.
• The Executive Board of WHO identified issues of
  critical importance
• a) shape PHC around the life patterns of the
  population
• b) involve the local population
• c) place a maximum reliance on available
  community resources

38
PHC WHOs New Approach to Health Development

• d) provide for an integrated approach of
  preventive, curative and promotive services for
  both the community and the individual
• 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
• f) provide for other echelons of services to be
  designed in support of the needs of the
  peripheral level and
• g) be fully integrated with other sectors
  involved in community development.

39
PHC WHOs New Approach to Health Development

• 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 develop-mental ones, for
  the promotion of PHC.

40
PHC WHOs New Approach to Health Development

• 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.

41
Reflections on the CMC

• 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 community-based
  health care, particularly applicable to less
  developed countries.
• Its subsequent reflections on fresh perspectives
  of both theology and health.

42
Alma Ata -- 1978

• One of the great events in the history of public
  health.
• U.S. Delegation Julius Richmond, Surgeon
  General Carl Taylor, Jack Bryant, Peter Bell,
  Ted Kennedy.
• Influenced the professional lives of us all.
• Bryant was then a staff person with President
  Jimmy Carter, and served on the Executive Board
  of WHO, thereby immersed in global health issues.

43
After Alma-Ata

• There were many events following Alma-Ata that
  tell us of the positive and negative sequences to
  the Alma-Ata Story
• There were anniversary meetings 10 years, 15
  years, 20 years, 25 years after Alma Ata, and I
  attended each of them.
• Here is a brief example.

44
10th Anniversary of Alma-Ata, RIGA, USSR, 1988

• 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.
• 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.

45
WHOs Role

• In a December 2003 article in the Lancet, WHO
  Director General, Lee wrote
• A crucial part of justice in human relations is
  promotion of equitable access to health-enabling
  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 todays context.

46
After Alma-Ata

• 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.
• Here is a listing of the major perspectives and
  processes of the 30 years since Alma-Ata

47
Changing Perspectives on PHC and Development

• Social Determinants of Health
• Selective PHC
• Neoliberalism
• Globalization
• Commission on Macroeconomics and Health
• Millennium Development Goals
• PAHO values, principles, elements of PHC
• WHOs new Director General
  Dr. Margaret Chan

48
Alma-Ata and Primary Health Care An Evolving
Story

• 2005 -- International Encyclopedia for Public
  Health, Elsevier Press, London.
• Asked J. Bryant, Julius Richmond, to write a
  chapter on Alma-Ata for the Encyclopedia.
• Agreed -- The work began in 2005. Wonderful to go
  back to the 1960s and 70s, reviewing the CMC
  story and related events.

49
Onward with the Chapter

• 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
  Chans commitment to Primary Health Careplanned
  a Conference on PHC and the MDGs, Buenos Aires,
  August, 2007
• Bryant, do join us for this important event! And
  he did!

50
Buenos Aires 30/15

• From Alma Ata to the Millennium Declaration.
• International Conference on Health for
  Development Rights, Facts and Realities
• Buenos Aires 30-15 Declaration Towards a Health
  Strategy for Equity, Based on Primary Health
  Care
• Honorary President Dr. Halfdan Mahler
• Honored Participant Dr. Margaret Chan

51
Bryant Chapter

• Elsevier Press agreed to inclusion in the Chapter
  of an Addendum, based on Buenos Aires.
• Bryant formulated the Addendum, based mainly on
  personal comments made by prominent members of
  the Conference
• There follows remarks made by familiar persons in
  leadership roles. It is so interesting to hear
  what they are saying in their own words!

52
Halfdan Mahler

• 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.

53
Ravi Narayan Peoples Health Movement

• I represent the people who are being left out!
• 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?
• Health for All needs a new paradigm.
• We have to move from top-down, vertical
  globalization, to a people-led globalization
  involving everybody from bottom-up.

54
Michael Marmot Social Determinants of Health

• There should be a partnership between social
  determinants of health and primary health care
  they need each other.
• High quality academic work is important, but we
  want to see academic work translated into action.
• We want to create a global movement that places
  fair health, health equity, at the head and heart
  of social policy.

55
Margaret Chan

• The topics explored in this conference (Buenos
  Aires, 2007) embrace some of the most pressing
  issues in public health today
• 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.
• What role can PHC play in this quest?
• 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?

56
Margaret Chan

• Apart from its passionate call for equity and
  social justice, Health for All also launched a
  political struggle on at least three fronts.
• First, it sought to make health part of the
  political agenda for development, to upgrade the
  profile of health and increase its prestige.
• 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.

57
Margaret Chan

• 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.
• 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.
• 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.

58
Mirta Roses Periago Towards an Equity Based
Comprehensive Health Care

• 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.
• 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.

59
Mirta Roses Periago

• Three points remain clear for all of us
• 1. We do not need weak, selective, or incomplete
  PHC that, as we say, is like a poor mans 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.

60
Mirta Roses Periago

• 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.

61
Mirta Roses Periago

• 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.

62
Reflections Buenos Aires

• It is such a pleasure to listen to the words of
  todays 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.
• Thank you Halfdan, Ravi, Michael, Margaret and
  Mirta.

63
Reflections -- CMC

• 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!