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SocMed Uganda 2015 Course Announcement – Reminder

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Greetings all,

A reminder that our application deadline is quickly approaching at the end of June.  We welcome applications from all interested health professional students.


Michael Westerhaus


On behalf of SocMed, we are please to invite health professional students to apply for the fifth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience offered on-site at Lacor Hospital in Gulu, Uganda from January 5th – 30th, 2015.  Beyond the Biologic Basis of Disease merges unique pedagogical approaches including community engagement; classroom-based presentations and discussions; group reflection; theater, film, and other art forms; patient clerking and

SocMed Uganda 2015 Poster

presentations; and bedside teaching.  These approaches create an innovative and interactive learning environment in which students participate as both learners and teachers to advance the entire class’ understanding of the interactions between the biology of disease and the myriad social, cultural, economic, political, and historical factorsthat influence illness presentation and social experience of disease.

The course curriculum places considerable importance on building partnerships and encouraging students to

reflect upon their personal experiences with power, privilege, race, class, and gender as central to effective partnership building in global health.  In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty andstudent colleagues.

In our annual Uganda course, thirty health professional students enroll each year, with half of the spaces filled by students from Ugandan medical and nursing schools, and the other half filled by international students from anywhere outside Uganda.  Credit for away-rotations can be arranged.

This course is offered through SocMed, a non-profit organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

More Information and Application Process

Further information and applications can be found in the Social Medicine Course Prospectus 2015 and on the SocMed website:   Please view short videos describing the course, publications related to the course, and advocacy videos created by previous students during the course by visiting the “Resources” tab on the website.

Applications are due June 30, 2014 and can be downloaded from the website.  If you have questions, contact us at

Please do not hesitate to contact us with any questions you have.


Amy Finnegan, Ph.D.

Phyllis Kisa, MB.Ch.B, FCS ECSA

Michael Westerhaus, MD, MA

SocMed Co-Directors

Cuba Leads the World in Lowest Patient per Doctor Ratio; How do they do it?


by Joanna Mae Souers

*Paraguayan 5th year student participating in primary care in Havana, Cuba. (2011,by Joanna Mae Souers)

In early 2007, I began studying medicine at the Latin American School of Medicine in Havana, Cuba.  I entered the program not knowing much about the Cuban healthcare system, other than that it was universal and free.  “Now that’s a system I want to learn from,” I thought to myself, “It’s a system we could all learn from.”  Five years later, what have I learned?

There are many subtle and not so subtle differences between the Cuban and the U.S. health care systems which have allowed the Cubans to equal the U.S. with respect to their health statistics, but at a much lower cost and with better preventative and primary care.  In this paper I analyze just one of the reasons for the differences between the two systems; Cuba produces more primary care practitioners per capita.  How do they do it? Medical education in Cuba is free, all doctors interested in specializing must first serve two years working in primary care, and graduating doctors are not driven to specialize by salary incentives.  This socialist approach towards medicine and medical education assures the human resources necessary to provide universal and preventative healthcare to all.

People marvel at how Cuba has “accomplished so much with so little.”  And they marvel with good reason.  According to the World Health Organization, Cuba spent only $503 per capita on healthcare in 2009, the U.S. spent almost 15 times that sum.  In fact we in the US spent $421 per person just on the administration of the private healthcare insurance system, almost enough to fund the Cuban system. [1] [2] Despite dramatically lower costs, Cuba has some of the best health statistics and health indicators of any country around the world.

Although people like to compare and contrast the health statistics of the U.S. and Cuba, I think this a bit preposterous.  Cuba, a small island in the Caribbean, is being compared to one of the largest countries in the Americas with a very different history.  So in the table below, I have shown some health statistics on Cuba and the U.S. as well as the Dominican Republic and Haiti.  The Dominican Republic and Haiti are Cuba’s Caribbean neighbors; similar in size, history and geographic location.

*Statistical information provided by the World Health Statistics 2011 Report by the World Health Organization.

From this table, we can see that Cuba’s health indicators are more like those of the “first world” in the U.S. than its neighbors in the “third world.”  The life expectancy of the U.S. and Cuba is almost identical.  Cuba supersedes the U.S. in the categories highlighted.  So we continue to ask, “How do they do it?”  Could it have something to do with their philosophy that people need doctors?  Hence, their solution is to offer a free medical education to develop young, quality doctors dedicated to serving those in need.

Per capita Cuba graduates roughly three times the number of doctors as the U.S.   In 2005 Cuba had 70,594 doctors.  Before the revolution in 1959, there were only an estimated 6,000 doctors; somewhere around half left the country after 1959.  This means they must have graduated an average of 1,469 Cuban doctors per year, not including the some 5,000 international students who graduate each year from Cuban medical schools. [3]  When we later compare these numbers to the U.S. we see that Cuba graduates 3 times the number of doctors per capita, and the U.S. must import graduating doctors from other countries just to fill the primary care residency positions.

Critics of the “Obama Plan” say that there will not be enough doctors in the U.S. to take care of all the patients if everyone has healthcare coverage.  Obama encouraged the Association of American Medical Colleges to increase the number of graduating doctors by 30% in 2010.  Ever since 1980, U.S. Medical schools have graduated 16,000 doctors a year.  Meanwhile, the population of the U.S. has grown 50 million during the same period.[4]  A 30% increase would have meant we should have graduated 20,800 medical students in 2010, but we only graduated 16,838 according to the Kaiser Family Foundation.[5]  The number of residency programs at teaching hospitals in the U.S. has been frozen since 1997, funded by Medicare.  There were 29,890 residency slots filled in 2009,positions not filled by American graduates are filled by International Medical Graduates. [4]   This means we can estimate more than 1/3 of students in U.S. residency programs are International Medical Graduates (IMGs), students from another country or a U.S. citizen, like me, who studied in another country.

In the current scheme of things, International Medical Graduates are continuously brought in to the U.S. to meet the needs of the growing patient population.  Unfortunately nothing bridges the gap, because there just are not enough residency positions and/or funding for teaching hospitals to produce enough doctors to satisfy the entire U.S. population.  Taking International Medical Graduates to meet the needs of the U.S. population only adds to the “brain drain” of developing countries around the world.  So as we produce fewer doctors, introduce more doctors from other countries; U.S. doctors work harder for less to meet the needs in the U.S. and a lot of the world remains catastrophically underserved.

Cuba leads the world with the lowest patient to doctor ratio, 155:1, while the U.S. trails way behind at 396:1.[6]  With a surplus of Cuban doctors, Cuba is able to help ailing nations around the world.  They have medical missions in over 75 different countries lead by nearly 40,000 health professionals, almost half of them are doctors.[7]  The United States by contrast imports doctors from poorer countries, further contributing to the brain drain of professionals from poorer countries to rich ones.

In Cuba education is free.  Room and board, books and amenities are included.  Doctors are not burdened by student loans and live comfortably though not extravagantly.  Harvard Medical School states in their admissions statement that an “un-married first year medical student” will spend approximately $73,000 for the 2011-2012 academic year.  This includes tuition, room and board, books, etc.[8]  Now times that by four and you have a whopping $292,000 to shell out to become a Harvard doctor.  With interest rates, loan deferments and default charges, you might end up like Michelle Bisutti.  She graduated medical school in 2003 with a $250,000 debt, in which by 2010 had increased to $555,000.[9] This may be an extreme case, but the Association of American Medical Colleges projected in their 2007 report that in 2033, students on a 10-year repayment program will only see half of their after-taxes salaries, the rest going to loan repayment.[10]

The cost of medical education in the U.S. causes more and more medical school graduates to turn to higher paying specialties and subspecialties rather than primary care or family medicine.  Dr. Thomas Bodenheimer writing for the New England Journal of Medicine, stated that “between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent,” based on data from the National Resident Matching Program. [11]  In the U.S. specialists predominate at a ratio of 2:1 (the reverse of other Western countries) while half of all outpatient visits are made by primary care physicians. [12]   This deficit of primary care physicians decreases people’s access to primary care and preventative medicine, causing increases in health disparities and healthcare costs.  This is because preventative medicine benefits the patient as well as reduces the number of Emergency Department visits and hospital stays.  If there are no primary care physicians to provide preventative care to the population, we see the population suffer as costs continue to rise.

* Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program. [11]

According to a survey in 2008 by the American Academy of Family Physicians, family medicine graduates with less than 7 years of experience earn, on average, a yearly salary of $145,000.[13]  The difference in earnings between primary care physicians and specialists differed by only 30 percent in 1980, and dramatically rose up to 300 percent for some narrowly defined specialists by 2009.  In the graph below, we show the dramatic difference between median compensation for selected specialties compared to that of primary care.[14,15]

*Median Compensation for Selected Medical Specialties.
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005. [15]

When working in the U.S., almost every primary care physician I talk to has the same complaint, “Too many patients, and too little time.”  They are forced to see 20 to 30 patients a day just to meet pay-incentives and “keep their doors open.”  General/Family Practice physicians spend an average of 16.1 minutes with each patient per visit. [16]   Meanwhile, 18%, or roughly 48.2 million of the U.S. population under the age of 64 is without healthcare insurance.  They have no access to most GP’s or family practice physicians. [17]

We need to follow our Cuban role model, we need to be held socially accountable and produce more primary care physicians.  This can be accomplished by providing an education at full scholarship to those interested in primary care, or by increasing the number of medical students going into primary care by closing the compensation gap between primary care and the higher paid specialties.  These measures would ensure the population better access to quality primary care and preventative medicine.  It would bring down the cost of healthcare while allowing primary care physicians to practice under less stressful conditions leading to quality affordable healthcare for all.


  1. World Health Organization (WHO 2011); Countries. []
  2.  “Healthcare Marketplace Project, Trends and Indicators in the Changing Marketplace (Exhibit 6.11: Private Health Insurance Admin Cost per Person Covered, 1986-2003),” Kaiser Family Foundation, Publication Number: 7031.  []
  3.  “Cuba and the Global Health Workforce: Training Human Resources.” Salud! (Source Vice Ministery for Medical Education and Research, Ministry of Public Health) []
  4. Sullivan, Paul.  “Discomfort at U.S. Medical Schools.” The New York Times; April 29, 2009.
  5.  “Total Number of Medical School Graduates, 2010.”  The Kaiser Family Foundation.  []
  6.  “World Health Statistics 2011,” World Health Organization; WHO Press, Switzerland.
  7. Brouwer, Steve.  “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity,” Monthly Review, 2009, vol 60, issue 8 (January).
  8. Harvard Medical School Admissions, “Costs (Updated: 7/21/2011).”  []
  9. Pilon, Mary.  “The $555,000 Student Loan Burden,” The Wall Street Journal, February 13, 2010.
  10. Fuchs, Elissa.  “With Debt on the Rise, Students Face an Uphill Battle.” The Association of American Medical Colleges, January 2008.
  11. Bodenheimer, Dr. Thomas,“Primary Care – Will it Survive?” New England Journal of Medicine, vol 355;9. Pg 861-862.
  12. Alper, Philip R. “Primary Care’s Dim Prognosis,” Hoover Institution, Stanford University, Policy Review No. 158 (December 1, 2009).
  13. American Academy of Family Physicians, Income (2011).      []
  14. Alper, Philip R. “The Decline of the Family Doctor,” Hoover Institution, Stanford University, Policy Review No. 124 (April 1, 2004).
  15. Woo, Dr. Beverly.  “Primary Care – The Best Job in Medicine?” New England Journal of Medicine, vol 355;9. Pgs 864-866.
  16.  “Healthcare Marketplace Project , Trends and Indicators in Changing Healthcare Marketplace (Exhibit 6.5: Mean Time Spent with Physicians (in Minutes), 1989 – 2002),”  Kaiser Family Foundation, Publication Number: 7031, Information Updated: 4/11/05.      []
  17.  “2010 National Health Interview Survey (Tables 1.1A-B, 1.2 B)”, Center for Disease Control.  []


Reminder: Social Medicine Course in Northern Uganda – Applications Due June 30th

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SocMed invites students to apply for the fourth annual course Beyond the Biologic Basis of Disease: The Social and Economic Causation of Illness, a social medicine immersion experience conducted on-site at Lacor Hospital in Gulu, Uganda from January 7, 2013 to February 1, 2013. This unique immersion course incorporates innovative teaching methodologies to merge teaching of clinical tropical medicine with understanding the socioeconomic, cultural, political, and historical underpinnings of illness. Through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions, the study of clinical medicine in a resource-poor setting is intersected with social medicine topics such as the social determinants of health, globalization, war, human rights, community-based health care, and narrative medicine. Enrollment is open to fifteen 3rd and 4th year medical students from across the globe, and includes equal participation of Ugandan medical students, and credit for away-rotations can be arranged.


This course is offered through SocMed, an organization that advocates for and implements global health curricula founded on the study of social medicine. By engaging medical students though careful examination of the social and economic contexts of health and immersing them in partnership with a diverse group of students from around the world, we aim to foster innovative leaders who are ready to tackle challenging health problems in communities around the world.

SocMed utilizes a curriculum that places great importance on building personal partnerships and encouraging students to reflect upon their personal experiences with power, privilege, race, class, gender, and sexual orientation as central to effective partnership building in global health. In the spirit of praxis (a model of education that combines critical reflection with action) these components of the course give students the opportunity to discern their role in global health and social medicine through facilitated, in-depth conversations with core faculty and student colleagues.  Please feel free to visit our website,, for more information about the course, its directors and guest lecturers, and SocMed.  Applications are due by June 30, 2012.


Please do not hesitate to contact us with any questions you have at




Michael Westerhaus, MD, MA

Amy Finnegan, Ph.D.

Course Directors

Magnum Foundation Emergency Fund Interviews Joyce Wong, LCSW & Ousara Sophouk of Montefiore’s Indochinese Mental Health Program

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Joyce Wong, LCSW

Ousara Sophouk










Joyce Wong LCSW , Social Worker and Ousara Sophouk, Family Health Worker at the Montefiore Family Health Center were recently interviewed by Pete Pin for a photodocumentary project – Displaced:The Cambodian Diaspora through the Magnum Foundation Emergency Fund. Mr. Pin, a fellow at Magnum Foundation, spent 5 months last year taking photographs of the Cambodian Bronx community. Joyce and Ousara speak about their 20 years of experience serving the Southeast Asian community in the Bronx. A link to the interview and photographs can be found on the Emergency Fund’s website.

Here is the text of the interview:

In early November, 2011 Pete Pin, EF Fellow, spoke to Joyce Wong, a licensed clinical social worker, and Ousara Sophuok, a Cambodian family health worker who immigrated as a refugee from Cambodia in 1986. Joyce and Ousara work together at Montefiore Hospital in the Bronx, New York where they provide mental health services to the Cambodian and Vietnamese Bronx community.

PETE PIN: Can you describe the clinic and the work you do here in the Bronx?

JOYCE WONG: We have been providing out-patient mental health services for the last twenty years as part of a collaboration between the Department of Psychiatry and Family Medicine. We are part of an urban medical center but we actually modeled our program after the Harvard Program in Refugee Trauma who were pioneers in the identification and treatment of torture and mass violence. With the program, mental health care is integrated in a community healthcare setting as a truly collaborative model of care.

Cambodian refugees were resettled in the Bronx in the mid-1980’s and came to our clinic for healthcare. However, physicians were not equipped to deal with a lot of the medical and psychiatric problems the patients presented. Not only were medical problems associated with lack of access to medical care—as many refugees were living and languishing in refugee camps between five to ten years—but many patients suffered from psychiatric trauma from the Khmer Rouge Regime (1975-1979).

In the mid 1980’s, we partnered with the departments of psychiatry and family medicine at Montefiore and developed a collaboration with a small mental health program to attempt to address some of these problems. At that time non-governmental organizations, especially abroad, addressed the problems of food, clothes and shelter for persons who had undergone mass violence, trauma and natural disaster. But the NGOs did not usually address their mental health needs. My colleagues at Harvard were one of the first to conduct scientific research studies when Cambodian refugees were living in refugee camps in Thailand, and found that high levels of depression existed within the refugee camps. When the refugees were resettled here in the Bronx , the focus on the mental health care needs of refugees was very progressive for that time. It was a holistic approach. This was over twenty years ago.

But how do you present mental health to someone who does not have a western frame of reference or worldview? A lot of the work in the first years was getting to know the community and going out to the community because you’re not going to expect someone to come to your door even if they are living across the street from your clinic. We established a motto of “Eat, Work and Play”: eating with the community, working with the community, and playing with the community. It meant attending weddings we were invited to, attending important religious holidays at the local Buddhist temple, conducting home visits to get a sense of the social issues that the people in the community were facing, walking up and down Fordham Road in the Bronx.

PIN: Were there things unique about the Cambodian community in regards to their trauma and their history that compounded the difficulty of providing services and hindered their ability as individuals and a community to assimilate and to make that transition from the camps to America?

WONG: It was very difficult for Cambodians because during the genocide between one to three million people were killed from a population of seven million. Much of the educated population of Cambodia was killed. Many of the surviving Cambodians that were able to flee and escape to refugee camps were rice farmers who didn’t have high levels of literacy in their own language or education. In contrast, many other immigrant groups came from countries where there was a solid infrastructure, where there’s a high level of educational attainment, and this really influences their experiences when they come to the United States. It affects their ability to navigate in their new home country and what opportunities are available to them on a day to day. The refugees that came to the Bronx from Cambodia were already a disenfranchised community and further marginalized because they were resettled in a physically and economically distressed community. To compound this, not being able to read and write, not having access to resources because of the language was a barrier on all levels: education, work, and health.

PIN: Sarah can you discuss your work in the community and how you became involved in the clinic? It’s important to stress to readers that you are yourself a member of the Bronx Cambodian refugee community, that you immigrated here under the exact circumstances as the people you have been providing services to.

OUSARA SOPHUOK: Joyce Wong had mentioned that during the war a lot of educated individuals were killed and the majority of our patients, especially the ones that came for care at our clinic, didn’t have a lot of formal education, including myself. During the war I didn’t have a lot of education, I only finished a few years in school. I escaped to a refugee camp where I studied English for six months. When I arrived to New York there was a temple three blocks from this clinic I went to regularly. That’s how the community got together. I arrived 1986 and I went to the temple where they had a Cambodian women’s program where I studied English.

One day there was a person from Adelphi University who was recruiting people for training in human services and a job program. They wanted us to go for field placement. At that time I didn’t know what I wanted so I said, “I want to work on something that relates to the community and I can help people” although I could not even help myself at that point. It was what I wanted to do, so they said “Ok you can do your field placement at the temple.” When I was doing my field placement my English was not great and I was so nervous to be doing the work. Then I looked at the people that were going to the ESL class at the temple, and I realized I knew more English than them because I studied it in the refugee camp. I said to myself, “These community members need more help than I do.” That’s what gave me a lot of courage to go to school. I went to the training for six months and at the time when I graduated from the program they were looking to hire someone to work in the mental health clinic for Cambodian and Vietnamese refugees at Montefiore.

I grew up in a family that served the community, which is where my desire to help others comes from. My father used to be a Buddhist monk in the Bronx temple and we went to the temple all the time. We prayed and ate together there so I really knew the community before I started working here. Like Joyce had mentioned, we had to eat and play so I went to the temple and I recruited people. I explained to them what I was doing and the services we had here. The people trusted me because my father was the monk in the temple and people trusted him.

PIN: When you approached people to talk about the services here, how did you phrase it, how did you talk to people? You obviously played a very pivotal role in the outreach.

SOPHUOK: At that time it was very difficult to translate from English to Khmer. The word psychiatrist, psychiatry or mental health literally translates to “crazy.” It’s a very strong word so I used the word “emotional health.” Instead of physical health I said emotional health and I explained to them that we have the clinic here and the doctor will take care of your physical health and we will take care of your emotional health. You have to educate the people that emotional and physical is the same, that they’re very connected to each other. This is critical because we went through a lot of trauma during the war.

At first, it was difficult for people to understand. Traditionally we didn’t talk about mental health and our feelings; we always suppressed this during the war. You didn’t say anything during the war, you kept everything inside to survive; you acted as if you were dumb. There’s a Cambodian word a ting mong meaning a scarecrow on the farm. We called ourselves a ting mong because we acted as if we didn’t know anything. We hid our intelligence to survive.

WONG: The Khmer Rouge had a slogan: “To destroy you is no loss, to keep you is no gain.” If you’re constantly told that you’re not of any value and disposable, something happens to your psyche which has ramifications for survival at that time but also psychological consequences in the future.

PIN: Is this something that you see manifesting itself decades after?

WONG: It was a coping mechanism during the war for survival, but as you said it had repercussions for the future. The a ting mong mentality became so ingrained during the genocide and the refugee years, that even after immigrating to the U.S. many Cambodians continued to wear that cloak. If you don’t bring the trauma into consciousness, then it continues to manifest itself and weigh on you every day.

PIN: You carry the weight of that with you. For me I think that’s very critical, the residual affects of trauma; that’s something the academic and resettlement community doesn’t widely recognize. There hasn’t been a lot of work on residual trauma, and this perspective is brand new in regards to the need to provide holistic, culturally sensitive mental health services to refugees that takes into account their unique circumstances.

SOPHUOK: We had to get people to understand that the clinic was a very safe place to talk about our emotional health. I had to convince them that if they said something wrong here they were not going to get killed and that here in the clinic we take care of their emotional needs. And then the people started to open their minds a little bit and began to trust us. After a few years, the program expanded by word of mouth, the doctors, and self referrals.

PIN: Please describe the community within the first year or two here in the Bronx, how their experiences were, even your experience, during that transition in the first several years of resettlement?

SOPHUOK: It was very difficult even for myself. I encountered a lot of difficulties even though I spoke a little bit of English. It was very scary to go outside and it was very difficult to go somewhere because of the culture shock. The culture was different. The living situation was different. The first years were difficult because we couldn’t go anywhere. We were like children learning how to walk step by step. We learned how to walk block by block. At that time we could only go to the temple and a Cambodian store that opened in the community. So people were not able to take the train or bus to travel outside of the neighborhood. We were both scared to get lost and confined. I’m of course talking about myself—that I felt confined—but I know that other people felt confined too. Imagine the older Cambodians who didn’t speak English. The first year was very difficult. Even now there are a lot of Cambodians who are ill and remain confined.

PIN: Yes. A lot of people don’t realize this. When I talk outside the Cambodian community the usual response is “that’s just the immigrant story,” that it’s the normal transition for immigrants when they resettle. As if all these issues can be generalized for all immigrants. However, obviously there are very unique circumstances that are endogenous to the Cambodian community as a result of the specific historical circumstances of their displacement and the resultant demographic outcomes as a result of the genocide.

WONG: Exactly. And refugees are disproportionately affected because of the multiple past trauma events of undergoing a war and genocide. The average number of trauma events a Cambodian refugee has undergone is 16. From torture, starvation, separation of family and friends, witnessing of killing, rape, and slave labor. So it’s not just acculturation, but the refugee’s past traumas and the resulting possible psychiatric distress and disability. Furthermore, these refugees were situated in economically distressed communities.

PIN: Please talk about the outreach in terms of strategies you talked about; eat, work and play?

WONG: Like our colleagues at Harvard, our approaches were a little unconventional and off-the-beaten path in trying to recruit and present ourselves in a way that community members would trust us. That really meant getting out there in the community and talking to people. Advocating for social changes, injustices. Challenging slum landlords in housing court, accessing social services, creating art programs that community members could participate in to beautify there community. The best forums usually are established places or places of faith, which play a very large role in community members’ lives. As Sarah said we often visited the temple on major holidays, made home visits, and attended weddings, funerals, religious ceremonies. We have always had a big component of also providing social services to meet the psychosocial needs of the community. We’ve had the privilege of being here for twenty years so we have followed people through the lifecycle; many of the patients grew up with us. We have been there through their marriages, through having children, through having teenage children, pregnancies, domestic violence, alcoholism, poverty, discrimination, deportation, etc. We really have run through the gamut in regards to problems and scenarios that community members have faced.

But one thing I think was pivotal for us during our time here is the realization that although mental health is very important, it’s important to stress economic and social sustainability. That comes from building community and empowering it through self-determination. So our approach has always been holistic. It was crucial when we partnered with the Committee Against Anti-Asian Violence in the Bronx, a grassroot organization in New York in the mid 1990’s. I just felt that at some point maybe six years after we started providing services, doors were closing on our community members. I didn’t feel they were progressing socially or economically; not because they didn’t want to but because of lack of investment of the US government and other institutions. So we partnered with The Committee Against Anti-Asian Violencethrough their youth leadership development project to organize and advocate for economic, social and health justice on behalf of the refugee community. We began to organize the community around other issues such as welfare rights, education rights, immigration rights, language rights, and accessing comprehensive healthcare. Witnessing the community mobilizing themselves and taking action was a highlight of my career. It was liberating to actually see the community developing consciousness and building its confidence.

If you ask me, as you’ve said before “how is it different?” I would say old models of recovery aren’t really effective anymore, and the humanistic/holistic approach to recovery is crucial. I really do feel hopeful with our community. I’ve seen that people really can recover from mass trauma and violence and can live very productive lives and can begin to trust other people again.

PIN: How have your patients progressed over this life cycle?

WONG: It’s a reality that some things may never really go away. Patients and community members still suffer from major depression; they still suffer from post-traumatic stress disorder. It doesn’t go away. But even if you have these psychiatric conditions, you can learn how to cope and live a fulfilling rich life. That’s huge. And that gives me hope. Our patients can still enjoy life, can still have positive healthy relationships with other people; you don’t have to be so isolated. I tell them they are not experiencing these things because of bad karma but because they underwent genocide and that it’s a normal reaction to terrible horrific events. I think it’s very reassuring and relieving for suffering people.

PIN: Sarah, can you elaborate on that?

SOPHUOK: I just want to add a point – about patients learning to cope and learning the result of the war was no fault of their own.  For some patients with severe psychiatric problems, the process was very slow.  We had to work very hard period. We encouraged them to do things that relieve them of suffering such as exercising, walking daily, socializing at the Buddhist Temple, engaging in meaningful activities, being of service to others.

WONG: This patient Sarah is referring to goes to the gym two to three time a week.  This was somebody who was completely homebound and confined when we started treating her 15 years ago.  She was paralyzed with her story and with her pain.  So she’s still limited in many ways but now she feels she has some control over the quality of her life and pain.  She can do things for herself; she can lead a more productive life. For us, progress doesn’t always translate into a job and although we feel work is a great value, being productive could also mean going to the park three times a week to meet your friends, or going to the temple on a daily basis. All of these activities are of great value and have a lot of healing qualities.

PIN: Again, that’s one of the issues: the old models of treatment are limited to the idea of providing English instruction and jobs.

WONG: Yes, it’s short-term thinking and a residual form of social welfare.

PIN: Yes, and what’s great about this is the fact that you have been providing services for over twenty years and it remains an ongoing process. You have acknowledged the reality that severe trauma does not magically go away.

WONG: Yes, it doesn’t go away but the way they see their lives, and the way they live their lives can still change. They are survivors, not victims anymore.

PIN: There’s a generation of Cambodians who immigrated here as teenagers or children, who came here when they were 14 or 15 and started high school here in the Bronx, or like myself were born in refugee camps but were raised in the inner-city; their experiences are very different because of their age. For the young Cambodians I met in the Bronx—and I think this goes across the board for all Cambodian diaspora communities in America—they have experienced their own unique forms of trauma inherited from their parents and compounded by the social ills of the inner-city.

When we started this interview, I played an audio clip of a teen I photographed in the Bronx who was speaking about her experience in regards to her parent’s trauma. You can hear a hint of trauma in her voice. For me it’s very profound how trauma can be passed on generationally. This is something I see in my own life. Have you treated people like this?

WONG: Yes, definitely. Within the last year there was a young Cambodian woman in her thirties and she was severely tortured during the Khmer Rouge.

This particular woman is a single mother with a seven-year-old daughter. She is one of the more traumatized and depressed patients that I have seen in a long time. It was just so clear how her depression and post-traumatic stress was affecting her relationship with her daughter. The little girl was taking care of her mother. Her mother was usually very depressed, very angry, and not able to parent her daughter in a consistent way. When I would ask, “Are you able to cook for your daughter or spend time with your daughter” she would respond, “No, I buy Chinese food or my daughter cooks her own meals.” Her daughter was going to sleep after eleven o’clock because her mother was not able to set boundaries and limits. The daughter was put in the role of an adult and that clearly affected the mother’s ability to be a parent.

Most of our patients are on psychotropic medication because it decreases their flashbacks, depressive and anxiety symptoms. This has helped her. Once her symptoms were relieved a bit, we were able to start talking about the importance of creating a secure and loving attachment with her daughter. When you’re that depressed it’s difficult to have an understanding of how your mental health problems can or are affecting your child and make the necessary changes.

PIN: What is your assessment of the community now? You’ve told me that you feel very hopeful, can you elaborate on that?

SOPHUOK: I feel very hopeful because our patients have received services and medication to help relieve them of their symptoms from trauma. They can now participate in community organizations like the Committee Against Anti Asian Violence and Mekong. With community organizational support, plus the temple our clinic that makes me very hopeful for the future. But still we need more. We do not have enough services for our community, which limits our progress but we have been actively working on Mekong.

Joyce Wong: I just feel hopeful to hear Cambodian youth say, “We want to be in charge of our community, we want to promote culture and dignity and we want to heal our community.” This makes me feel very hopeful. With these ideas we began to envision Mekong an emerging organization in New York City that will serve Southeast Asians by trying to improve the quality of life through community organizing, promoting arts, culture, language, and social services. It is a holistic approach to community organizing. Since last year we have been working with CAAAV to transition the Youth Leadership Project into an independent organization after a community needs assessment of Southeast Asians was conducted by emerging local leadership. On March 29, 2012 we will officially launch Mekong and that is something to celebrate and embrace. I would like to think that I’ve contributed a little grain of sand that creates hope and power.




EF Fellows are recent photojournalism school graduates who work as editorial assistants for the Emergency Fund and simultaneously create New York City-based photo stories on a topics consistent with the EF mission to “address critical issues that have not received the attention they deserve, or budding crises that are still over the horizon.”

posted by: Matt Anderson, MD

Reminder: Social Medicine Course in Northern Uganda – Applications Due July 31st


We invite medical students to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as the social determinants of health, globalization, global health interventions, war, human rights, community-based health care, and narrative medicine. This highly interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.

For more information, we invite you to please see our website at: . In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: and 2011:

If you have any questions or are interested in applying, please email us at Applications are due July 31, 2011.

Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA

IPHU Bronx 2011: An Introduction to the PHM



Today we came together on this first day of the IPHU from all over our small planet:  Ghana, Guinea, Haiti, Kenya, Lebanon, Puerto Rico, Russia, Rwanda, Thailand and the United States.  The day begins with introductions that are more than asking this group of inspiring and eloquent agitators the bland recitation of names, organizations and what are you interested in; we are asked to speak of ourselves through our personal and social mandates, or, what is the change you wish to see in the world and how do you see it?  As  brothers and sisters, we respond with a passion born of being fed up with a global system that perpetuates inequality and injustice at the cost of the health of our communities, and speak of our hopes and common threads of the need for advocacy, speaking truth to power, and alternative models and ways of thinking about health and health care that is people centered, not profit focused:  “Health for all Now,” “Love Solidarity,” “Access,” “Health Activism,” “Meaningful Participation,” “Progressive Work,” “Mental Health,” “Englightening,” “Bright Future,” “Visual Healing,” “Cultivate Love,” “Health Education,” “Awakening,” “Education Action.”


Next, David Legge gives a comprehensive overview and history of the People’s Health Movement, International People’s Health University (IPHU) and the People’s Health Charter (PHC).  We go over this radical document, a unifying, organizing vision that views health as a right for ALL.  This profoundly simple understanding is so fundamental, that some of us in our small group discussions ask, “Why Not?” Not “Why Not” as this is a good idea, but “Why Not” as in why is this socially, economically and just idea not implemented and what do we as advocates and activists need to do to push this forward, use this in our work, and what do we need to include (LGBT rights, more emphasis on gender inequality, and a suggestion to create a handbook on how to use the PHC)?


Laura Turiano follows with a presentation on using a Human Rights based approach to advocate Health for All Now.    Next follows participants’ big task:  group work on our projects that advance the idea of Health for All in our communities.  Our task at hand:  present our projects with our compadres in small groups where, over the course of the week, we will support each other to: analyze, re-think, re-fine, conceptualize, strategize, and put into action our vision of the world and communities in which we wish to live.


The “formal day’s agenda” concludes with a brief introduction of the Theatre of the Oppressed by John Sullivan.   Free form movement and human sculptures is what we are and mold ourselves into as we attempt to convey the fundamental values and concepts of the days proceedings:  Hope, Inspiration, Thinking, Motivated…all conveyed through our bodies, expressions, and movements.  The consensus over dinner discussions and late night debates, rabble rousing, getting to know you sessions, is:  this is going to be a great, learning filled, intense, memorable week.


Register now for Doctors for Global Health 2010 Annual Meeting

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Doctors for Global Health will be holding its 16th Annual General Assembly from July 29th to the 31st at Loyola Marymount University in California.  You can register now at: The People’s Health Movement (PHM)/USA circle will be holding a pre-conference meeting in the days preceding the conference.

The theme of the Assembly is Community Action for Health and Social Justice: Health Begins Where We Work, Live, and Play.  Here is a synopsis of the Program:

Keynote Speakers: America Bracho and Theresa & Blase Bonpane

Dr. America Bracho is the Executive Director of Latino Health Access a community health center in Orange County, California.  She was the subject of a 2009 profile by Bill Moyers which discusses her work as a community organizer.

Theresa and Blase Bonpane are founders of Office of The Americas, an educational group dedicated to furthering the cause of justice and peace in the hemisphere.  The Office sponsor a weekly radio program on KPFK (Los Angeles) called World Focus.

Panel discussions:

Health and Human Rights of Migrant Communities

  • Steven Wallace, PhD- UCLA Center for Health Policy Research
  • Kyrsten Sinema- Arizona State House of Representatives
  • DREAM Act students
  • Irma Cruz Nava, MD- CEPAFOS, Oaxaca, Mexico
  • Samaritans Patrol of Arizona

The Right to Food and Food Justice:

  • Anuradha Mittal- Executive Director of the Oakland Institute
  • Anje Van Berckelaer, MD- Robert Wood Johnson Clinical Scholar
  • (others TBA)

Other activities:

  • Tour of Father Greg Boyle’s Homeboy Industries and Skid Row
  • Physicians for Social Responsibility discussion on nuclear technology
  • Update on People’s Health Movement-USA
  • Lively conversations, networking, socializing, and music
  • Updates from DGH partner communities in Mexico, El Salvador, Peru, Guatemala, Sierra Leone, Uganda, and Burundi.


Please register now at

posted by Matt Anderson

Social Medicine Course in Northern Uganda (2012)


We invite you to apply for the third annual Beyond the Biological Basis of Disease: The Social and Economic Causation of Illness, an on-site immersion course in social medicine offered at Lacor Hospital in Gulu, Uganda from January 9, 2012 through February 3, 2012. This intensive course designed for 15 international medical students (clinical years) and 15 Ugandan medical students (3rd-5th year) from Gulu University intersects the study of clinical medicine in a resource-poor setting with social medicine topics such as globalization, war, human rights, and narrative medicine, among others. This highly-interactive course is taught through a combination of lectures, small and large group discussions, films, community field visits, ward rounds, and clinical case discussions. Credit for away-rotations can be arranged.

For more information, we invite you to please see our website at: In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: and 2011:

If you have any questions or are interested in applying, please email us at Applications are due July 31, 2011.

Michael Westerhaus, MD, MA
Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
(course instructors)

Barriers to Accessing Health Care for Asians: From the Bronx to Cuba

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For 20 years Joyce Wong, a friend and colleague, has worked as a licensed clinical social worker  with the Cambodian and Vietnamese refugee community in the Bronx.  We wanted to share with readers of the Portal some of her recent work examining immigrant health care both in the Bronx and in Cuba.

Throughout the years she has been involved in training medical residents and students on refugee mental health in addition to organizing with the Committee Against Anti-Asian Violence (now called Organizing Asian Communities)  in the area of language rights for the Southeast Asian community. She contributed a chapter, on the mental health and resiliency of elderly Chinese  men in Cuba, to the book Community Health Care in Cuba. She is a native New Yorker who grew up in Washington Heights to parents from Puerto Rico and China.

Accessing Health Care: From the Bronx to Cuba

In 2010, Ms. Wong was interviewed for Asia-Pacific Forum, a program on New York radio  station WBAI.  The interview (available at this link) examined barriers to health care access for two different Asian immigrant communities. The first was the Southeast Asian refugee community in the Bronx who have faced challenges to obtaining language access and quality health/mental health care.  (See our prior posts on the Justice is Healing campaign). She then turned to Cuba where she shared her research on health access for the Chinese-Cuban elderly male population in Havana.

La Magia de Cuba

During her visits to Cuba for the book chapter, Ms. Wong produced a short photo-video documentary entitled La Magia de Cuba, for a course on global mental health at the Harvard Program in Refugee Trauma on healing environments. It needs no commentary or introduction. Enjoy:

Ms. Wong is planning to return to Cuba this year to expand her research on elderly Chinese men with a plan to publish a book with Professor Eric Tang, University of Texas.  A fundraising event will take place  later this spring and we will keep readers informed.  She can be reached via email.

posted by Matt Anderson

PHM activist Dr. Ravi Narayan @ Liberation Medicine Course

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On Friday, October 8, Dr. Ravi Narayan of the People’s Health Movement visited the Bronx to talk about his work; he spoke as part of the Liberation Medicine Course run by Dr. Lanny Smith. The talk took place in Dr. Smith’s apartment where some 30 students and health activists gathered to hear Dr. Narayan. Food was provided by Dr. Mario Chavero, a visiting psychiatrist from Rosario, Argentina.

Participants in the Liberation Medicine Course. Dr. Narayan in black Tshirt.

Dr. Narayan began by noting that this was his second trip to the Bronx. He had spoken to students at Albert Einstein College of Medicine in 2003 when he and his wife, Thelma, had presented at the GHEC conference in New York. He was here now as adviser to the Obama Administration’s Inter-Faith Initiative and also to consult with PAHO about community health. He seemed a bit bemused by the fact he had been invited to work on faith-based topics, but learned he had been chosen because of his work (see below) in getting several religious groups in India to work together.

Dr. Narayan told us he represents a collective of people still enthusiastic about the goal of Health for All.

Medical Training and Work in Refugee Camps

Dr. Narayan is a physician and graduated from medical school in Bangalore in 1971. After graduation and “quite by accident” he went to work in refugee camps along the border with Eastern Pakistan (now Bangladesh). As background, he told us that there were nine million refugees who walked across border into India because of a rampage by the Pakistani Army. Their sole crime was to participate in a democratic election. In this election the East Pakistanis (the majority in Pakistan) had voted for their own leader; in principle he was to become the Prime Minister. The West Pakistanis objected and sent the army to East Pakistan. The refugees walked across the border into western India where the government set up some thousand camps. A liberation struggle developed in East Pakistan which would eventually become the independent state of Bangladesh.  Seven to eight months after this exodus, the refugees returned home.

The experience of working in the camps caused a paradigm shift in his thinking. Were it not for this paradigm shift, he might have ended up on the east coast of the US, the goal of many well-educated Indian physicians. In fact, he noted with a wry smile, during this trip to the US he had been meeting with many of his old medical school classmates. Instead of coming to the US, however, he had been transformed by the “very human experience” of being a doctor working with a community. He had learned to listen, to see patients as participants in their own lives, to consider mental health, and to look at the social context of health. He had been exposed to a series of experiences – genocide, rape – which had been absent from the medical school curriculum. He was challenged to look at social, political, economic determinants that he learned very little about in medical school.

After working in the camps, he returned to the medical college and specialized in public health and preventive medicine. These were, he noted, the only specialties that would allow him to continue to work with people in the community as opposed to working in the hospital or outpatient clinic. He would later get a public health degree from the London School of Tropical Medicine and Hygiene and do further studies at the All-India Medical School (“India’s Johns Hopkins”).

Teaching Community Medicine

For 10 years he had taught in the St. John’s Medical School Department of Community Medicine trying to replicate for students his experience in the community of the camps. He found lots of support from young doctors who had been involved in natural disasters and been transformed by “the moving experience” of working with a community. His wife, Thelma, had this type of experience when she worked doing disaster relief. While he  described teaching this course as “10 years of great fun”, there were problems. The Department worked in five clusters of villages and they kept coming across problems, such as caste and gender, which were not medical. It was frustrating for the faculty not to be able to offer students “solutions” to these problems. Dr. Narayan cited a specific example. They used growth charts (called the “Road to Health”) to detect malnutrition in children. Over time it became clear that the children of dalits, the lowest case group, always had third degree malnutrition. “No matter what you did” it proved impossible to improve their nutritional status. The biomedical tools just did not work. They tried community-based interventions; he had attempted to organize unions. But this was a dangerous activity and he had been accused of being a Marxist. At the time, he said, he didn’t know what this meant, but he had read up on Marxism subsequently.

The faculty was frustrated and disturbed by the failure of biomedical solutions. They realized over time that medical schools always limited in their analysis to the biomedical part of problem and this led, inevitably, to a technical solution (usually a drug or vaccine).  Even when a social determinant was apparent, physicians kept it out of their thinking. After all, dealing with determinants was not taught in medical schools. They were also concerned that although they started each course with a definition of health, in the end the curriculum was entirely about ill-being. Finally, they were bothered by medicine’s orientation towards individual problems with no appreciation of collective responses.

Foundation of SOCHARA

In 1984 Dr. Narayan and three other members of the department left the medical school (“this symbolized our walking out of the biomedical model”) and established the Community Health Cell, SOCHARA. Other faculty would join them later. Rather than dealing with health problems, they wanted to work with people interested in wellbeing. They did not want to work with dispensaries, hospitals or drugs.  Rather, the wanted to work on health, wellbeing, and social determinants; they are not so concerned with medical problems.

Their focus shifted from doctors and nurses and they began to work with farmers, teachers, women, and street children. By 1990 SOCHARA was busy. It had grown by word of mouth and they were very happy doing this sort of work. They purposely avoided an academic institutional affiliation and they did not start any programs of their own. Rather they helped people to form their own networks.

But by 1990 they became increasingly aware of how decisions made in Delhi and elsewhere (he mentioned Washington) were affecting them. Malnutrition in Bangalore began to increase because millet was no long available cheaply on the local market; it was being exported. Development did not seem relevant to the people in the area, rather it benefitted other people who lived someplace else. The example of millet export showed how agricultural policy was relevant to malnutrition. They set out to study economics and social conditions.  SOCHARA by this time had an extensive network of alumni and contacts, so when they came across something they did not understand, they found a colleague who was an expert. Sometimes what they learned made sense and sometimes it didn’t. They often felt that the social sciences helped to understand what was going on, but didn’t provide tools to make things better.

In 1992 India accepted a World Bank’s Structural Adjustment Program and made significant cuts in social benefits. The result was to further polarize society. Bangalore, Dr. Narayan’s home, was now the most globalized city in the world. The expression “to be Bangalored” meant to have your job moved to India. Around his family home you could find all major multinationals within walking distance. But whereas 400 million Indians were now living in the globalized world (“I can eat McDonald’s or Kentucky Friend Chicken and wear Nike shoes”), 800 million Indians “don’t even get the basics.” There are two Indias now.

People’s Health Movement in India

By 1999 SOCHARA had come to feel the need for a countervailing power which could speak truth to power from the bottom up. This was the impetus for the formation of the People’s Health Movement in India. During its history SOCHARA had worked with 18 large networks and in 2000 they called them together in a meeting in Hydrabad. It was a diverse group which included Marxists, Gandhians, and Christians. Five representatives of each network assembled on April 7th 2000, divided themselves into working groups, and produced “five little books.” These book examined what globalization had done to health, to primary health care, and to basic needs. The content of the books was then converted into popular formats (cartoons, songs) and used to mobilize some 300 communities. In December 2000, some 2500 people packed into four trains and came to Calcutta for first national People’s Health Assembly; this launched the national PHM of India.

As an interesting side note, Dr. Narayan briefly discussed the armed resistance to British colonial rule. He noted that although we, as Americans, would be surely surprised to hear this, it was not Gandhi who had forced the English out. Rather the English left because large sections of the army had deserted (to join the armed resistance) and the country had become ungovernable. “As a result, we went from one group of Brahmins [i.e. the British], to another and the revolution was incomplete.” He sees this failure as the reason that 1/3 of India is currently under a Maoist insurgency and they (like many other progressives) are often accused of being Maoists.

Formation of an international People’s Health Movement

“Of course, internationally we were not alone.” Similar initiatives had been going on in a number of countries and in December 2000 a meeting was held in Savar, Bangladesh which founded the international PHM.  The resultant People’s Health Charter went beyond Alma Ata. He is in love with the charter: “2 pages of problems and 6 pages on how to fix it.”

Speaking of PHM, Dr. Narayan noted: “It’s a movement, you can’t pay to join it.” The work of the People’s Health Movement has evolved into four main activities: 1) the development of country circles which range from a few people who communicate by list serves to large national organizations with state and district level committees (India), 2) the publication of  Global Health Watch every five years, 3) holding of International Peoples Health Universities, 7-10 day training programs for activists from around the world, and 4) the organization of  the international  People’s Health Assembly every five years.

After 10 years of existence, he felt that PHM is now getting to be well known. Many articles have been published about PHM or by PHM members. Discussion of PHM now appears in textbooks of global health. PHM has been described as the “globalization of health solidarity from below” a description he feels is apt. He now devotes his energies to talking to students in public health and challenges them that: “If your professors aren’t teaching you about PHM, perhaps they are dinosaurs.”

Questions from the Students

“You make it sound easy, but surely there were difficulties.” Dr. Narayan noted that he had offered us just a ‘short story’ about their work, and that yes, it was a challenge and a struggle. They had been victims of political persecution. But he also noted that one of the largest challenges was to change what is inside of ourselves. They have a fellowship program (Community Health Learning Program) which is a six week experience of the movement. Two weeks are spent at SOCHARA and there are two additional two week placements elsewhere. This fellowship allows people to become familiar with their work. Their principles for selecting people are two. They only take people who are confused; “if you’re not confused, you don’t need us to teach you.” They also feel that you can’t be part of the solution unless you realize you are part of the problem. Fellows, for example, need to unlearn professional biases. “You need to see every person as a participant.” But he also stressed the importance of professionals sharing their knowledge (to demystify things) as well as accepting that other people had expertise that they did not. There needs to “eyeball to eyeball” communication, i.e. communication between equals.

“How did SOCARA succeed in getting diverse groups to work together?” Dr. Narayan addressed this question by pointing to some of the traps into which organizations fall. The first was elite capture which occurs when an elite group (perhaps the academics) takes over an organization and other groups are marginalized. There was ideological capture in which different groups competed to see who was the most left.  He feels it is important to ask: “Is this policy pro-people or pro-market?” Finally, there was individual capture in which a charismatic person takes over the organization.

“How did you get paid when you worked at SOCHARA?” First, they had to accept that they wouldn’t earn as much they would in other areas. Second, they don’t require people to be full time; there are many degrees of participation in SOCHARA. Salaried staff were actually quite few. When he was the PHM global coordinator, the movement only had four salaried people in the entire world.

Two other speakers followed Dr. Narayan. Samuel Mwenda Rukunga,  from PHM Kenya, discussed their work providing health care and advocacy in the context of religious health care institutions.  Manoj Kurian MD, Program Executive of  Health and Healing, World Council of Churchs discussed how religious faith informed his advocacy for health for all.

Interested readers may also want to look at our interview with Dr. Narayan published in 2005 in Social Medicine.

Posted by Matt Anderson