For more information, we invite you to please see our website at: https://sites.google.com/site/socialmeduganda/ . In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011: http://www.youtube.com/watch?v=Z2UCUFcXAas.

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

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

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.

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.

EARLY BIRD REGISTRATION PRIOR TO JUNE 1ST. SCHOLARSHIPS AVAILABLE FOR STUDENTS AND ANYONE WITH NEED!

Please register now at www.dghonline.org

posted by Matt Anderson

For more information, we invite you to please see our website at: https://sites.google.com/site/socialmeduganda/. In addition, short videos of our previous courses can be viewed by clicking the desired year: 2010: http://www.youtube.com/watch?v=gLHGpY4EDwg&feature=related and 2011: http://www.youtube.com/watch?v=Z2UCUFcXAas.

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

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

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

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

posted by Matt Anderson, MD

We’re writing to remind you that applications are due in just over two weeks (July 30, 2010) for this exciting social medicine and global health course held in Northern Uganda. Please see the course invitation below and feel free to let us know if you have any questions:

Course Invitation 2011
We invite you to apply for the second 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 10, 2011 through February 4, 2011. 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 also be arranged. It is estimated that total student costs for the course will be $2650. This total includes roundtrip travel to Uganda from the US ($1700), full room and board in the hospital guesthouse ($500), and a course fee ($450).

For more information, we invite you to read the attached prospectus and view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

Sincerely,

Julian Jane Atim, MD, MPH
Amy Finnegan, MALD, MA
Michael Westerhaus, MD, MA
Brigham and Women’s Hospital
Division of Global Health Equity
Boston, MA 02115

Discussion in 2010 Course

For more information, we invite you to view the short video about this year’s course, available at:

If you have any questions or are interested in applying, please email us at social.medicine@yahoo.com. Applications are due July 30, 2010.

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

Healthy People 2010 focused on two main goals: increasing quality (and quantity) of life for Americans and eliminating health disparities.  Dr. Koh demonstrates that the results have been mixed. For 28 focus areas, ranging from access to quality health services to oral health to vision and hearing, just over half have seen improvement and nearly 20% have seen their target met.  By some measures, we have either remained discouragingly far from stated goals or actually worsened.  Cigarette smoking, for example, which is the leading cause of preventable death worldwide, decreased from a baseline of 24% in 1998 to 21% in 2008, far from the stated goal of 12%.  We are significantly more obese as a nation than we were ten years ago.  Approximately 1/3 of all adults over 20 years of age are obese, up from under ¼ two decades ago.  Unfortunately, the gains and losses in the health of Americans are not equally shared.  The goal of eliminating disparities remains, according to Koh, “unmet.”  Increased rates of obesity, for example, are greater in Blacks and Mexican Americans than they are in Whites.  Dr. Koh cites a review by Sondik et al (3), who demonstrate numerous examples of increased disparities in indicators of quality of life and overall health. They conclude that “overall, in the area of disparity reduction, there is not much good news.”

Dr. Hemenway points out that “it is generally acknowledged that public health is systematically underfunded and that shifting resources at the margin from cures to prevention could reduce the population’s morbidity and mortality.”  He cites four reasons for the underfunding of public health:  first, the benefits of public health measures are not immediate and therefore require a delay of gratification.  The costs are immediate but the results are both distant and unpredictable.  Second, “the beneficiaries of public health measures are generally unknown.”  Money flows more readily towards identifiable victims than hypothetical victims of future events.  Third, the benefactors of public health intitiatives are unknown by the beneficiaries: “when people benefit from public health measures, they often don’t recognize that they have been helped.”  The current TEA party movement provides a wonderful, if tragic, example of this, blind as it is to the concrete benefits of taxes and government.  Fourth, public health efforts often suffer from disinterest or, worse, outright opposition.  Hemenway cites “status quo bias” and “tradition-bound resistance” as examples of human characteristics that impede progress in public health initiatives.

It is reasonable to hypothesize that the systematic underfunding of public health initiatives contributes directly to disparities in health care.  And it is likely that the Healthy People Initiative will never realize the goal of eliminating disparities until public health funding can be consistently and meaningfully funded.  After all, it is the poor, the under- and un-insured, who tend to benefit most from public health initiatives like vaccinations, clean water supply, and clean air, and who suffer disproportionately in their absence.  Michael Harrington, in his landmark book, The Other America (1962), wrote about an America that was “hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.”  Nearly five decades later, these problems have not gone away.  As Healthy People 2010 comes to an end, in some cases they are worse.

It might be tempting to use Healthy People 2010 as an example of the ineffectiveness of public health initiatives.  Or one could argue that the Healthy People initiative sets unrealistic goals.  I would argue that the US government has a chance to prove otherwise with Healthy People 2020.  As the DHHS plans for the next decade, healthcare professionals must push our legislators to assure adequate funding for the public health initiatives that improve all of our lives in unseen but measurable ways.  We must urge them to block out the loud voices of those who would stop paying taxes without knowing what taxes pay for.  Finally, and most importantly, we must ask for more coordination between those that initiate public health interventions and those that measure the results.  Those who implement public health programs must work directly with those who establish goals for their efficacy. Measuring our own failure can only be of value if we have the means to turn it around.

1.  Koh H. A 2020 Vision for Health People. NEJM 2010;362:1653-6.

2.  Hemenway D. Why We Don’t Spend Enough on Public Health. NEJM 2010;362:1657-8.

3.  Sondik EJ, Huang DT, Klein RJ, Satcher D. Progress toward the Healthy People 2010 goals and objectives. Annu Rev Public Health 2010;31:271-81.