The Social Medicine Portal

Cutting edge Social Medicine 2011: Resident Projects from the RPSM

What is the cutting edge in Social Medicine in 2011, at least in the Bronx?

The 18 social medicine projects completed by the 2011 graduates of Residency Program in  Social Medicine offer one perspective.  These projects cover a wide variety of topics; three were conducted internationally (Quito Ecuador;  Andhra Pradesh, India; and Rwanda). Among the questions addressed were:

1) Are medical schools and residency programs accountable to the broader society?

2) Does the promotion of Zumba dance in the clinic  improve the health of diabetics?

3)  What are the barriers to reproductive health care among homeless adolescents living in shelters?

4) What is a social medicine doctor?

The abstracts published below represent work by residents in Social Pediatrics, Family Medicine, and Social Internal Medicine/Primary Care. The actual presentations were made during Social Medicine Rounds on May 24, May 31 and June 7, 2011.

 The objectives of this study are to obtain information about where teenagers receive their information about sexual health topics, to obtain information about the use of the internet/social networking, and to evaluate adolescent knowledge concerning reproductive health. Male and female adolescents between the ages of 14 and 21 were recruited from two urban clinics in the Bronx. They were asked to complete an anonymous survey which included basic demographic information, internet availability, a knowledge assessment, and questions assessing sources of information and their usefulness. Participants were also asked specifics about websites/social networking resources utilized. Responses to survey questions were tabulated in Excel and descriptive statistics were calculated.

One-hundred and eighty-nine adolescents were surveyed during their clinic visits. The median percent correct on knowledge questions was 64.7%. The most common sources were medical professionals (93%), mothers (85%), friends (86%) and the internet (83%). Information provided by medical professionals was seen as the most useful (92%) followed by mom (81%), boy/girlfriend (79%) and the internet (73%). The most common websites used were Google (74%), Yahoo (26%), and Wikipedia (26%). The top four search terms were sex, condoms, birth control, and HIV.

To assess the potential of group visits in comparison to individual visits, a Centering Parenting Model of group well-child care was implemented at a Federally Qualified Health Center in an urban primary care setting designated as Patient-Centered Medical Home.

Study participants are parent-baby dyads and are established patients at the Family Health Center. Centering Parenting groups consisting of 5-10 pairs meet at predefined routine well-child visits to receive routine well baby care in a group setting.

The purpose of this project is to provide group well child care as an alternative to individual provider care with the hope of improving quality outcomes and parent satisfaction.

 Background: Cervical cancer is a completely preventable disease. Yet 470,000 new cases of cervical cancer are diagnosed each year and 300,000 women die annually worldwide. The overwhelming majority of these cervical cancer cases occur in the developing world. Pap smears are the main screening test for cervical cancer but many developing countries lack the infrastructure to perform pap smears. To address this need for cervical cancer screening in the developing world, the medical organization Prevention International: No Cervical Cancer (PINCC) developed a mobile service which screens for precancerous cervical cells using direct visual inspection of the cervix with acetic acid (VIA) and immediately removes suspected lesions in a single visit using either cryotherapy or LEEP. This study aims to evaluate the effectiveness of PINCC’s mobile cervical cancer screening program in Andhra Pradesh, India.

Methods: For 12 days in August and in December 2009, PINCC went to a different village each day in Andhra Pradesh, India. Mobile cervical screening using VIA was performed on non-pregnant, non-menstruating women between the ages of 23 and 75 who did not have signs of vaginitis. Pap smears were often performed for VIA-negative lesions, or if the squamocolumnar junction (SCJ) was not fully visualized because it extended into the cervical os. Biopsies were taken of VIA-positive lesions. Cryotherapy was performed if VIA-positive lesions covered less than 75% of the cervix and there was adequate visualization of the SCJ. Women with VIA-positive lesions covering >75% of the cervix received LEEP. PINCC referred all women suspected of having cervical cancer to the local hospital, based on the screening VIA results and biopsy. These women did not undergo cryotherapy or LEEP treatment.

Results: PINCC screened 623 women for cervical cancer during the 24 days that they were in Andhra Pradesh, India. Cervical samples from only 543 women were used in this study since there were missing data for 80 screened patients. Of the 543 women screened, 431 were VIA-negative and 112 were VIA positive. The VIA-negative group included 391 completely normal cervical screening after adequate visualization of the SCJ and 40 women who had to undergo pap smears for inadequate visualization of the SCJ. Precancerous cervical cells were found in 3 of 40 pap smears. Of the 112 participants with positive VIA lesions, 21% had cryotherapy, 27% had LEEP, and 45% were biopsied only without treatment due to either a non-functional cryotherapy or LEEP. Squamous cell carcinoma was found in 1.3% of the screened women. Of all the 112 VIA-positive lesions seen, biopsies found cancer or precancerous cells in 53 women, for a positive predictive value of 47%.

Conclusions: In 24 days, PINCC effectively screened 543 women with the low-cost method of VIA and immediately treated them with cryotherapy or LEEP. The PPV of VIA to detect precancerous cells was similar to other studies involving VIA. Further measures need to be taken to reduce the number of samples with missing data and to ensure operational equipment. A mobile “see and treat” model is a feasible method to address the high cervical cancer rates in the developing world.

The Montefiore Transitions Clinic (TC) was established to provide access to primary care, mental health services and social services for recently incarcerated adults. In July, 2009, we established a TC for recently incarcerated adults through partnership with Bronx Parole Board and The Osborne Association, a local prisoner advocacy community based organization (CBO). Initially, referrals to TC were primarily from parole officers and the overall burden of chronic illness was low. Here we report on the impact of a community health worker (CHW) on patient recruitment and disease severity.

To evaluate the impact of the referral source on the disease prevalence seen at TC, we performed a retrospective chart review comparing patients seen before and after the CHW was hired. Data was available for the first 39 TC patients, of whom 38 were referred by the Parole Committee, and the 30 most recent TC patients, 29 of whom were referred by the CBO through the CHW. Our primary measure of interest is prevalence of chronic disease in TC patients, including HIV, hepatitis C, mental illness, opioid dependence and diabetes. Secondary measures include time from correctional facility release to first clinic visit and insurance status.

With the assistance of a CHW, the TC has reached a population of former inmates with a higher burden of chronic illness. Referrals from a CBO, coordinated by a community health worker, identified a population with a high prevalence of chronic diseases including HIV, hepatitis C, mental illness and opioid dependence. system of facilitated referrals, along with access to health centers where barriers to care are minimized, can help bridge gaps in care for the formerly incarcerated population.

Needs and Objectives: Although weight loss can lead to a reduction in diabetes and hypertension and improve health outcomes, only 42% of obese U.S. adults report that their physicians have counseled them about weight loss. Even when weight loss is advised, most physicians do not discuss specific weight loss strategies, indicating that the quality of counseling may be poor. To address this gap, we adapted, implemented, and conducted a pilot evaluation of a previously developed theory-based obesity counseling curriculum for residents using a 5A’s behavioral change model. In this model, residents are trained to assess obesity risk, agree on mutual goals, advise a weight-control program, assist in establishing appropriate intervention, and arrange for follow-up. The objective of our evaluation was to determine the feasibility and impact of a novel obesity counseling curriculum, which incorporates training and practice in obesity counseling skills, on residents’ self-assessed competency in obesity counseling.

Setting and Participants: Our target audience was 28 interns and residents in the Primary Care/Social Internal Medicine Residency Program at Montefiore Medical Center, Bronx, New York.

Description: The curriculum was delivered 4 times over a 6 month period to groups of 5 to 10 residents during ambulatory medicine blocks. One week prior to curriculum participation, residents completed a previously validated survey with 9 items measuring self-assessed obesity counseling competence, based on the 5A’s model. Each question used a 4-point likert scale. The 3-hour 5A’s Obesity Curriculum included a 2-hour didactic and discussion session on the epidemiology of obesity, 5A’s obesity counseling framework and practical tools for its implementation. Case-based discussions of treatment modalities included behavior change, medication, and surgical options for weight loss. The final hour involved reviewing motivational interviewing (MI) and practicing with a standardized patient. Two months after participation, residents completed a post-intervention survey, and gave general feedback. Preliminary analyses compared median scores before and after curriculum participation using the Wilcoxin test.

Evaluation: To date, 16 residents have completed the curriculum and surveys, with another 10 scheduled to participate. Residents reported their counseling competence in: 1) assessing patients’ stage of change, 2) diet and 3) current level of physical activity; 4) agreeing on mutual goals for weight loss; 5) assisting patients in goal setting for weight loss; 6) responding to patients’ questions about behavior change; 7) offering medication and 8 ) surgical weight loss options; and 9) using MI techniques to change behavior. After the curriculum, there was a significant increase in the median scores from 2 to 3 (2=somewhat able to perform, 3=able to perform adequately) in residents’ report of assessing stage of change, assisting in goal setting, discussing treatment options and using MI techniques. There were no differences in the remaining domains. On qualitative questions, residents reported a high degree of satisfaction with the curriculum and requested additional skills practice sessions in MI.

Discussion: We developed and implemented a novel curriculum for residents to address strategies for weight loss using the 5A’s behavior change model, which incorporated obesity counseling skills practice. Preliminary pre and post curricular analyses showed improvements in several areas of residents’ obesity counseling competence. Implementing this three hour curriculum in a residency program was feasible. Post curricular questionnaires indicated that residents were satisfied with the curriculum, and were eager for additional sessions for continued practice and refinement of obesity counseling using MI skills. Further evaluation, with additional learners, and direct observation of counseling skills is needed to fully elucidate the impact of the curriculum in promoting effective obesity counseling skills.

Chronic malnutrition is associated with childhood mortality and affects up to a quarter of children in Ecuador. In southern Quito, lack of knowledge and poor diet diversification are contributing factors. Existing research has shown health education is a critical component in influencing behavioral changes and local collaborators, such as the Ecuadorian Ministry of Health and community physicians, have identified health education as an area that merits further investigation in their patient population. Hence, the objective of our study was to assess the effectiveness of a health education intervention given at a government-run clinic in Quito, Ecuador.

A 20-minute workshop and pictogram handouts were developed to provide education on the effects of protein malnutrition and highlight locally available protein sources. The workshop was offered daily over a 4-week period and the handout was distributed to a subset of patients after the workshop. Oral questionnaires were developed to assess protein nutrition knowledge, confidence in participant’s own knowledge, and protein intake pre- and post-workshop and at home visits three weeks later. A total of 98 participants completed pre- and post-workshop questionnaires and 57 completed home visit questionnaires. We found that knowledge and confidence increased after protein education workshops with retention at home visits. The utilization of pictogram handouts in educational sessions improved protein intake. These findings support continuing to work with Ecuadorian collaborators to further develop one-time, concise educational interventions to improve dietary behavior.

[This presentation won the Daniel Leicht Social Medicine Award and the Chairman's Research Award.]

Purpose: Seen as a public good, graduate medical education (GME) was financed by Medicare 1965, expecting that this responsibility would continue “until the community bears the cost in some other way”. Over 40 years later, Medicare is still bearing the brunt of GME financing, spending $9.5 billion last year. Many have suggested that academic health centers have become dependent on such financing. We sought to better understand the perceived responsibility of GME institutions in addressing the needs of the nation, and the utility of and most likely methods to measure and compare the social impact of GME institutions.

Method: Eighteen informants were interviewed via semi-structured interviews done by phone and in-person. Key informants were chosen from salient national agencies/associations after developing a sampling matrix to ensure appropriate breadth of perspectives. Snowballing technique was employed, and informant interviews were continued until saturation of themes was achieved and confirmed via search for disconfirming data.

Results: Seventeen of eighteen informants noted that GME institutions have a responsibility to be socially accountable. Informants’ definitions of social accountability included: training of future physicians, addressing workforce shortages and providing service to the institution’s community. Multiple informants noted barriers to measuring social accountability, though many informants suggested possible tools for measurement of social accountability.

Conclusions: GME is largely seen as a public good, and multiple informants noted that recipients of GME funding should be responsible to their communities. However, time constraints, financial limitations, and curriculum overload limit GME institutions’ ability to be socially accountable. Financial incentives, accreditation requirements and maintenance of mission values can address GME institutions’ responsibility to medical education, workforce shortages and community service.

Prison release rates in New York City correlate directly with poverty rates, and a disproportionate number of prisoners are returning to the Bronx. Recently released individuals attempting to reintegrate into the community are among the most marginalized of populations and have grave health outcomes. RPSM residents provide care for many of these patients who are directly or indirectly impacted by incarceration. The goal of this project was to develop a longitudinal training program in correctional health for family and internal medicine residents. Methods included reviewing existing correctional health training programs, interviews with medical and academic directors, rotations and site visits to correctional facilities and transitions clinics in San Francisco and New York City.

The proposal for a longitudinal correctional health curriculum is comprised of required clinical and didactic components: Transitions Clinic sessions at FHC and CHCC during elective blocks throughout residency as the foundation; health education workshops, targeted outreach and discharge planning at Rikers Island and VCBC; buprenorphine training and case-based discussions with a substance abuse specialist; and cross-track conferences to discuss syllabus readings. Residents interviewed unanimously support a longitudinal model of learning and this proposed curriculum provides an example of a rigorous training program to meet their educational needs.

Description: During the academic year 2010 – 2011 we initiated an iterative educational process to engage residents in a dialogue about SBP. An anonymous web-based survey was sent to all 19 PGY2 and 3 residents asking them how they would handle four common clinical scenarios that occur when the resident is not in clinic or between patients’ clinic visits: (1) following up of critical lab values; (2) scheduling non-routine follow-up appointments; (3) handling urgent care situations when patients call from home; and (4) titrating medications. Each scenario was derived from our clinical experience and piloted with colleagues prior to survey distribution. Results were analyzed and a set of best practices was created. At a program-wide retreat attended by approximately 25 residents and faculty we moderated a two-hour discussion on the survey results, best practices and other SBP topics identified. A second anonymous survey was sent to the same 19 residents assessing the value of monthly SBP meetings.

Evaluation: Seventy-four percent (14/19) of residents responded to the initial survey, with up to 5 solutions given for each scenario. Responses varied by the skill level of the clinic staff member asked to assist with the task, the number of phone calls, emails, and hand-offs required, and the time needed for task completion. Given the heterogeneity of responses a set of best practices, emphasizing non-physician resources, was created and disseminated. Our second survey used a 5-point Likert scale (5=Quite Valuable, 1=No Value) to quantify the value of monthly SBP discussions. One hundred percent (14/14) of responders reported that sessions would be valuables or quite valuable. We then initiated monthly discussions (60-75 minutes) during ambulatory blocks (4-8 residents/month). To date we have held two sessions. Prior to each session we solicit SBP topics and distribute a resident derived agenda. Afterwards, we email key takeaway points and post updates on our program’s searchable website.

Background: Chlamydia and gonorrhea (GC) screening in specific populations, including substance users, is recommended. Entry into methadone maintenance treatment presents an opportunity to screen a high risk population, yet the prevalence of Chlamydia and GC infection in this population has not been well-defined. To address this gap, we began to routinely offer screening to women admitted to our Bronx methadone maintenance treatment program (MMTP).

Methods: A chart review of consecutively admitted adult female patients from June 1, 2010 is underway. Using a structured chart review instrument, we abstracted sociodemographics (age, race, income), substance type, injection use, trauma and incarceration history; HIV antibody status, syphilis titer, and urine GC and Chlamydia results.

Results: Forty-nine women were entered treatment between June and December 21, 2010. Eleven (22%) self-identified as Black, 32(65%) as Hispanic. Their mean age was 40 All had heroin dependence. Thirty-one (63%) reported cocaine use. Twenty-two (45%) had injected. Eleven (22%) had experienced domestic violence and 30(61%) had been incarcerated. Nine (18%) were HIV positive, and five (10%) had serologic evidence of syphilis infection. None of the 46 (94%) women tested for GC and Chlamydia were positive.

Conclusions: Although women entering MMTP are typically considered at high risk for sexually transmitted diseases, routine testing GC and Chlamydia testing did not identify any infections. The HIV and syphilis infection rates we found warrant routine screening, but the absence of GC and Chlamydia in this population does not thus far support routine screening with drug use as a sole risk factor.

Purpose: It is clear that social conditions contribute to ill health. This was described as early as the 19th century by Rudolf Virchow, generally considered the founder of social medicine. Yet, medical training continues to center on the molecular basis of disease. In efforts to create a different model of physician training, the Residency Program in Social Medicine (RPSM) of Montefiore Hospital was founded in 1970 to train a cadre of socially-minded physicians dedicated to providing care for the underserved. The RPSM is a holistic curriculum that encompasses an understanding of social problems affecting the health of individuals and communities and strategies for addressing these issues, while training in community health centers. This study investigates what encompasses a social medicine physician today, and how their practice differs from other primary care doctors.

Methods: All current residents, faculty and alumni of the Residency Program were eligible to participate in the survey, which was emailed in March 2009. A survey monkey questionnaire was used, and emailed to current department members and an alumni list-serve. The complete survey had seven items that included status (resident, faculty, or alumni); specialty (Family Medicine, Internal Medicine, Pediatrics); questions about the role of social medicine in regards to their practice, how it differs from other primary care doctors, and questions regarding the RPSM curriculum. Demographic data describing the participants was tabulated, and comments were grouped into themes and investigated via textual and qualitative analysis.

Results: The survey was completed by 173 participants. Forty-seven percent were in the field of Family Medicine, 30% in Internal Medicine, and 24% in Pediatrics. Fifty-six percent were alumni, 26% were faculty, and 21% were current residents. There were three main themes that were common to most responses, which were that social medicine doctors 1) have a broad knowledge of the social determinants of health, 2) have the ability to translate this broad knowledge of health into a specific treatment plan, and 3) promote social justice. Within each theme were various sub-themes which provided a richer description of social medicine concepts and its practice contrasted with the practice other primary care physicians.

Conclusions: Social conditions are not separate from medical conditions, an integral concept of social medicine and RPSM. Although this study was limited in that not all potential subjects responded and responses varied greatly in length and description, the concepts of social medicine are clearly central to their practice of medicine. Social medicine is thought to be valuable and essential in the treatment of individuals and communities, and an opportunity for social change. This model of medicine was viewed as fundamentally different from the practice of other primary care physicians. Further research in the practice of social medicine on patient outcomes, and perspectives of patients treated by social medicine doctors could be helpful in substantiating our findings and expanding the number of social medicine residency programs nation-wide.

The Patient Centered Medical Home (PCMH) has received attention as a cost-effective way to address the myriad problems facing the US primary care system. As more practices become PCMH’s, staff must carry out this change, however their perceptions of the PCMH and the change process may not be congruent. We will compare staff opinions of the PCMH transformation at two primary care clinics in the Bronx, NY, using focus groups consisting of providers and support staff, and analyze recorded transcripts for themes. We anticipate the analysis will yield insight into perceptions of the PCMH and the capacities of the clinics to carry out their transformations that will be useful to other practices as they begin their own transformation processes.

 Numerous studies demonstrate the deleterious health outcomes associated with substance abuse and dependence. To intervene early in the course of substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT) has been advocated by many.Few studies have examined the feasibility of or outcomes associated with conducting SBIRT in hospitalized patients. Although data regarding SBIRT for drug use has been sparse, with the rise in opioid use, abuse, and dependence, many advocate for SBIRT specifically for drug use. We sought to test the feasibility of conducting SBIRT for problematic opioid use targeting patients hospitalized on the medical wards of a large urban academic medical center.

We identified adult patients who were admitted floors of the medical wards and administered audio computer-assisted self-interviews assessing theirof problematic opioid use using the WHO ASSISTscreening tool.Patients were categorized as having no opioid use, or low, moderate, or high risk of problematic opioid use. Those who had moderate or high risk problematic opioid use received a brief computer-based intervention. We found that 42 (56.0%) reported no opioid use, 4 (5.3%) low risk, 26 (34.7%) moderate risk, and 3 (4.0%) high risk of problematic opioid use. Of the 29 patients with moderate or high risk, 19 (65.5%) were interested in referral to treatment and 27 (93.1%) reported that the brief computerized intervention was useful. We question whether our model of conducting SBIRT-with a dedicated person outside of the team delivering health care-is feasible. However, this urban inpatient population seems at significant risk thus more research is warranted on how to best use SBIRT to intervene on problematic opioid users in the inpatient setting.

Zumba Bronx is a reproducible and sustainable form of dance exercise that is built on one of the strengths of an underserved community, the passion to dance. Dance aerobic exercise has been shown to improve participants’ s BMI. The 2010 ADA noted that a 5-10% decrease in weight translates into a decrease in HbA1c. The literature review indicated that successful programs for weight loss have consolidated exercise, diet, and behavior modification plans. In addition, studies have illustrated the utilization of pedometers as a useful tool to motivate diabetic patients to increase physical activity and maintain these efforts. The goal of this social medicine project is to promote physical activity for patients with diabetes at the Williamsbridge Family Practice. The study will utilize this culturally appropriate, and cost-effective form of dance exercise, Zumba, coupled with pedometers, and develop patient centered support that can be incorporated into the FHC and CHCC health centers in the future. The objective of this project is to provide diabetic patients with the tools to develop and maintain a healthy lifestyle.

The purpose of this study was to evaluate whether a dedicated immigrant health session within a larger primary care practice can achieve retention in and quality of health care for immigrants. This was a retrospective cohort study with medical record review of all new patients seen at the OPEN-IT clinic at CHCC from October 1, 2007 to September 30, 2009. The primary outcome was retention in care, defined as at least one follow-up visit within one year after the initial visit. Secondary outcomes included rates of age-appropriate cancer screenings and results of specific screening tests as recommended by the CDC for refugee populations, including Hepatitis B surface antigen, tuberculin skin test, complete blood count, and ova and parasites in stool. Results showed that 79% of patients were retained in care, with no detected difference in retention based on age, gender, length of time in US, or presence of chronic illness. Rates of mammography and cervical cancer screening were 82% and 79% respectively, but the rate of age-appropriate colorectal cancer screening was only 24%. We also found that over a quarter of patients screened had evidence of latent tuberculosis, anemia, and intestinal parasites, although our numbers were small. Our results support the need for clear recommendations regarding immigrant-specific screening. Further work needs to be done to improve rates of colorectal cancer screening within our model and to better understand which diseases need to be screened for in the immigrant population.

Medicines have meaning and these meanings affect both their efficacy and their perception of it. Perceptions about efficacy affect adherence to and retention in treatment. Observations by substance abuse clinicians suggest that patients in methadone maintenance treatment(MMT)hold perceptions about methadone and methadone doses that may not reflect current medical understanding about methadone, including about interactions and adverse effects. Literature about the experience of patients in MMT is sparse, and this study aims to understand the experience with and perceptions about methadone among patients in an urban methadone clinic. Individuals in substance abuse treatment are a marginalized population. It is anticipated that a better understanding of their experience in a particularly stigmatized realm of medical treatment will allow clinicians to better understand their needs, their response to treatments with potential for interaction to methadone, and thereby improve the adherence to and retention in methadone treatment.

 Homeless adolescents experience multiple barriers to contraceptive use and they have high rates of unintended pregnancy and poor birth outcomes. The goal is to conduct semi-structured interviews with homeless female adolescents ages 14-18 at family shelters in the Bronx and to have teen educational seminars at a homeless family shelter. Interviews include questions on demographic data and open-ended questions regarding beliefs about contraception, experiences with accessing reproductive healthcare, future plans, and specific barriers to accessing reproductive healthcare as an adolescent living in a family shelter. Teen seminars focus on pregnancy, sex, and STDs. The purpose of our study is to 1) describe the experience of unintended pregnancy, abortion, and contraceptive use; 2) identify barriers to reproductive healthcare access including contraception; and 3) describe preferences for reproductive healthcare access in homeless teens. This data will generate data for targeted changes in services.

 A survey of pregnant Rwandan women’s use of complementary medicine.

Human Rights, State Repression and Sedition in India Or, Why are Kartam Joga, Kopa Kunjam and Binayak Sen in Jail? January 18, 2010 In New York City

For New York City readers, we wanted to post information about the following forum on Binayak Sen:

Panel Discussion moderated by Vasuki Nesiah, Associate Professor, NYU Panelists  include:

Peter Rosenblum, Clinical Professor of Human Rights Law, Columbia Law School Prof. Rosenblum served as the Associate Director of the Human Rights Program at the Harvard Law School, before joining Columbia University. He has had a wide range of experience outside academia, including Human Rights Officer with the Geneva-based precursor to the Office of the UN High Commissioner for Human Rights, Program Director of the International Human Rights Law Group, and Researcher for both Human Rights Watch and the Lawyers’ Committee for Human Rights.

Meenakshi Ganguly: South Asia Director, Human Rights Watch.  Meenakshi Gnaguly has investigated a broad range of issues from police reform to discrimination against marginalized groups, and has researched abuses surrounding the sectarian riots in Gujarat, the lack of justice in Punjab, issues of religious freedom, the failure to protect India’s vulnerable communities–including those affected by the Maoist conflict, and abuses related to the fighting in the states of Manipur and Jammu & Kashmir. She has also advocated a human rights approach to India’s foreign policy particularly on countries like Burma.

Somnath Mukherji:  AID-India and Free Binayak Sen Campaign Activist, Bhopal Advocate.  Somnath Mukherji has been a volunteer with Association for India’s Development for 8 years working with grassroots groups in India, on various developmental issues. He is also associated with the International Campaign for Justice in Bhopal and other campaigns within AID. He works closely with people in the Sunderbans on agriculture, Aila rehabilitation and other issues. Somnath has been involved with the International campaign working for the release of Dr. Binayak Sen since early 2008. He is based in Boston and spends some time every year working with grassroots groups in India.

The discussion will be preceded by a Photo feature by Journalist Javed Iqbal.  Javed Iqbal is a journalist with the New Indian Express doing reportage on tribal dispossession and conflict in tribal areas across the states of Orissa, Jharkhand, Chhattisgarh, MP and Andhra. Over the past few years his work has been key in exposing the myriad ways in which violence by all parties has wrought devastation in indigenous areas and violated law, due process, rights, livelihoods, community and entire ways of living. His reportage and photographs have become a key part of understanding the extent of these violations in the central heartlands of the country.

Who are Joga, Kunjam and Sen?

On December 24th 2010, a sessions court in Raipur, Chhattisgarh state in India convicted Dr. Binayak Sen, a medical doctor working for indigenous people for nearly 30 years and a renowned civil liberties activist. Along with two others (alleged Maoist leader Narayan Sanyal and businessman Piyush Guha), Dr. Sen was convicted under the draconian Chhattisgarh Special Public Security Act and Unlawful Activities Prevention Act was sentenced to life imprisonment for ‘sedition and conspiracy against the Indian state.’ Dr. Sen has been challenging human rights abuses by all parties in the state and the state sponsored vigilante group – Salwa Judum. He was earlier arrested in 2007 and granted bail after two years.

In 2007 Kartam Joga participated in petitioning India’s Supreme Court regarding human rights violations in Chhattisgarh and impunity for security forces and Salwa Judum. Joga has been in Dantewada district jail since 14 September 2010. Like Dr. Sen, Kartam’s conviction is under the draconian CSPSA and UAPA acts.

Kopa Kunjam is an adivasi youth leader working with the Gandhian organization Vanvasi Chetna Ashram for justice, peace and democratic rights in the tribal villages of Dantwada and Bijapur in Chahttisgarh. In recent years, he had been helping people defend their rights against abuses by state, police and Salwa Judum. Framed under murder charges, Kopa was arrested on 10th Dec 2009. In 2005, the Salwa Judum movement was started with state support in Chhattisgarh to oppose the Naxalites. With state backing, the Salwa Judum began committing serious human rights abuses, including killings, beatings of critics, burning of villages, and forced relocation of villagers into government camps. As a prominent leader of the human rights group People?s Union for Civil Liberties (PUCL), Sen called for an end to Salwa Judum abuses. He also opposed the Chhattisgarh Special Public Security Act, criticized human rights violations such as torture, extrajudicial killings and campaigned for improvements in prison conditions.

For additional background see the January 5, 2011 Human Rights Watch Statement on the Indian Sedition Law.

RSVP to: PSampat@gc.cuny.edu , dwai@nyu.edu

State-Sponsored Oppression: the unjust and outrageous life sentence of Dr. Binayak Sen

Dr. Binayak Sen

On 24 December 2010 the court of Raipur, state capital of Chhattisgarh, India, rewarded the health and social justice life of pediatrician Dr. Binayak Sen not with honors, medals or an honorary degree, but with a sentence to life in prison.

The message from the Government of India: if you work as an advocate with the poor, you are against the government and will be punished severely. It is a message to any who would work toward a more just world, in accompaniment of the marginalized, stigmatized and poor.

Dr. Binayak Sen, who is vice-president of the Indian Human Rights organization PUCL (People’s Union for Civil Liberties) and is the recipient of the 2008 Jonathan Mann Global Health and Human Rights Award, was accused of transporting letters for a jailed Maoist leader who was under his medical care. Though the prosecution showed nothing but circumstantial evidence (better said, no evidence at all—all visits of Dr. Sen with the prisoner were attended by prison guards, none of whom saw any letters, and two of whom were declared “hostile” by the court when they testified that it would have been impossible for such an exchange of letters to happen), the judge ruled—using as the Lancet editorial (see below) notes “a section of the penal code first introduced by the British to quell political dissent and later used to convict Mahatma Gandhi”—that Dr. Binayak Sen is guilty of “sedition.”

Outrage at such treatment of a man many consider mentor, hero and teacher resounds globally in journals such as the Lancet (Lancet 377:98 on 8 January 2011, “Binayak Sen’s Conviction: A Mockery of Justice”) and British Medical Journal (BMJ 2010; 341:c7438 “Civil rights groups decry conviction of Indian paediatrician who pioneered community health”) and within the press in India.

See: Facts about the Dr Binayak Sen case – The Times of India http://timesofindia.indiatimes.co. m/india/Facts-about-the-Dr-Binayak-Sen-case/articleshow/7125220.cms#ixzz1AbSIjDmn

Physicians for Human Rights (PHR) has called for Dr. Binayak Sen’s release.          http://physiciansforhumanrights.org/library/news-2008-05-20.html

Dr. Binayak Sen has worked for many decades with the poorest of the poor. He is well known as an advocate for health and social justice, an outspoken critic of police brutality. Apparently, his effectiveness is such that the Indian Government feels the need to silence him.

Go to http://www.binayaksen.net/ to learn more about the intricacies of the case and the condemnation of the court ruling, including a recent article concerning Nobel Laureate Amartaya Sen in the Times of India, in which he is quoted as saying: as an Indian citizen and a human being, I must exercise my own judgment to ask if this is correct. Sedition means pulling the state down by violence. It cannot be suggested that Binayak did this. On the contrary, his writing indicates violence is wrong. There is a deep moral argument against sedition here [in Binayak Sen’s book]. Amartaya Sen goes on to say of the ruling against Binayak Sen: It has a threatening nature and seems to have political motivation. Any intelligent person would find that the judiciary acted very peculiarly. I hope the high court or Supreme Court quashes this.

Dr. Binayak Sen is a member of Jan Swasthya Abhiyan, the PHM (People’s Health Movement) India. He has touched the lives of many—and this is perhaps considered his greatest crime, the crime of being a positive example.

Dr. Binayak Sen was first arrested in 2007. Though he has severe cardiac disease, he was kept without adequate treatment for two years—until an international campaign, including several Nobel laureates, achieved his provisional release on bail.

When a government punishes work dedicated toward health and social justice, it is making a statement that is global in nature. Its action must then be denounced globally. Please consider acting now in solidarity with Dr. Binayak Sen. Address the government of India with its own shame, by signing the petition directed to The President of India, Rashtrapati Bhavan: http://www.petitiononline.com/sen2010/petition.html

Consider expressing in print your disappointment that this sentence, egregious and wrong, has happened. Inquire into the health, not just of Dr. Binayak Sen, but of the patients who he has not been and will not be able to attend to because of his sentence. Demand that, in the name of justice, as well as health, the sentence be refuted (still legally possible by the Supreme Court of India) and his work instead granted the affirmation it deserves.

Please share what is happening to Dr. Binayak Sen with colleagues, local community members and your own government representatives, no matter where you live. Consider writing to him yourself, to express your solidarity and your appreciation of his example.

PHM activist Dr. Ravi Narayan @ Liberation Medicine Course

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

Upcoming International People’s Health University (IPHU) short courses: India, Morocco, Cuba

From our Friends at the People’s Health Movement: USA Circle

PHM and IPHU are pleased to announce the upcoming IPHU courses in India (September 21-30, 2009), Morocco (September 21-30, 2009) and Cuba (November 4-14, 2009). For details and registration, go to http://phmovement.org/iphu/. US health activists are encouraged to attend.

The International People’s Health University (IPHU) is one of the major programs of the People’s Health Movement. IPHU is a global university providing short courses and other resources for health activists. Courses are of a high academic standard and are documented for academic credit from established universities. IPHU short courses enable younger health activists, in particular, to make new connections, share experiences and study together. IPHU short courses strengthen the global network of people’s health activists.

Morocco – http://phmovement.org/iphu/en/morocco, in French and Arabic, Fes, Morocco
India – http://phmovement.org/iphu/en/bangalore/announcement, in English, Bangalore. This course is focused on Health and Equity.
Cuba – http://www.phmovement.org/iphu/en/CubaAnnounce, in Spanish and English, Havana

Social Medicine V4N1: Health Activism from Philadelphia to India

We have just published the 12^th edition of Social Medicine/Medicina Social, our bilingual, online journal.  It is available in both English and Spanish.  Our 12th issue captures the stories and struggles of diverse health activists, among them Dr. Walter Lear (shown below):

US Health Activism Collection

Last summer we had an opportunity to interview Dr. Lear (now 85 years old), founder of the US Health Activism Collection.   In a wide-ranging interview in his home Dr. Lear discussed his personal background, the origins and purpose of the collection, the impact of the McCarthy period on the US health left, as well as his vision for the future (available at this link).  Dr. Lear later added copious footnotes to his interview creating a virtual “Who’s Who” of the mid-20th century US health left.

Dr. Lear also allowed us to make PDF copies of two of the pamphlets in his collection. These are Autopsy on the AMA: An Analysis of Healthcare Delivery Systems in America [1970] published by the Student Research Facility and Your Health Care in Crisis: A HEALTH/PAC Special Report [1972] [Both documents are a bit long and may take some time to download.]  Although HEALTH/PAC no longer exists as an organization, there is a HEALTH/PAC website.

Seize the Hospital to Serve the People

We are also publishing a video of Cleo Silvers, a remarkable Bronx health activist who was involved in the takeover of Lincoln Hospital.  (For more on this take over see our spring 2007 journal)  The video of Ms. Silvers can be seen at our Audio/Visual tab.

Should India Use Commercial Ready To Use Therapeutic Foods (RUTF) For Severe Acute Malnutrition (SAM) ?

Indian Activists associated with Jan Swasthya Abhiyan (People’s Health Movement – India) and the Right to Food Campaign question the value of Plumpy Nut, an Ready to Use Therapeutic Food (RUTF).  They argue that locally produced alternatives are cheaper, more acceptable, and serve to strengthen communities.  At the very least Plumpy Nut should have been compared to local supplements before being adopted by the government.  Available at this link.

Combatting Organ Tafficking

Activists Debra A. Budiani and Kabir Karim of the  Coalition for Organ-Failure Solutions discuss the social roots of organ trafficking and consider the implications of  a 2008 WHO resolution and the Istanbul Declaration.  Available at this link.

posted by Matt Anderson, MD

Society for Community Health Awareness, Research and Action (SOCHARA)

[This post, by Naveen Thomas, was originally published in June of 2005]

In January 1984, a group of doctors and other professionals who left their jobs in mainstream medical colleges started a community health study-reflection and action group in Bangalore, South India. Community Health Cell (CHC) which grew out of this group, was supported by the Centre for Non-Formal and Continuing Education, Bangalore, till 1990. In June 1990, the project was reviewed and the Society for Community Health Awareness, Research and Action (SOCHARA) was established and registered. Community Health Cell became its functional unit.

As the name suggests, the main aim of SOCHARA was to promote community health awareness, action and research. SOCHARA’s mandate also included evolving educational strategies in Community Health and Development. SOCHARA recognised the need to dialogue and participate with policy makers and implementers to enable the formulation and implementation of community oriented health policies. As a part of efforts to promote community health, SOCHARA also established a library, documentation and interactive information center in Community Health.

SOCHARA consists of 32 members who are distinguished in their own areas of work. CHC, the functional unit of SOCHARA consists of a small core team of 20-25 people, including health and social science professionals, office and library team, research and training assistants, supported by a large informal network of professional associates and friends. The strength of SOCHARA has been its wide network leading to a rich and diverse web of interaction among persons and groups involved in Community Health in India and across the globe.

SOCHARA/CHC have been involved in participatory community health training at middle and grassroots level, primarily with voluntary agencies in South India. On the medical education front, CHC collaborated with the Rajiv Gandhi University of Health Sciences, Karnataka to reorient the vision and mission of medical colleges, to improve their management and to introduce medical ethics, rational drug education and other socially relevant topics in the medical curriculum. In addition, SOCHARA/ CHC were also involved in research on strategies for social relevance and community orientation of Medical Education and follow up initiatives with colleges and universities.

Promotion and awareness building concerning rational drug prescribing, rational drug policy, patents and alternative systems of medicine is another area of SOCHARA/ CHC’s functioning. SOCHARA/ CHC also took an active part in the recent Global Campaign against Indian Patents Amendment (GCAIPA).

SOCHARA/CHC has been providing active support to research and awareness building on environmental health issues including mining, Bhopal gas disaster, etc. The other disasters that SOCHARA/ CHC has been actively involved in facilitating relief and rehabilitation efforts include the Bangladesh cyclone disaster, Uttarkashi, Marathwada and Kutch earthquakes and Tsunami in Southern India.

Over the past two decades, SOCHARA/CHC have been motivating and guiding young professionals who were in the process of reflecting about their personal interest or commitment to community health. They spent 3 – 12 months in CHC where they went through a learning process that was person-centred, with peer support, short assignments, self-study, presentations, writing of reports, etc. Today, over 95% of the professionals continue to work in the area of community health.

A review of SOCHARA/CHC in 1998 and subsequent reviews suggested that CHC expand its training and mentoring role. As a result, a Community Health Fellowship Scheme commenced in April 2003, providing an opportunity for young professionals to learn about community health and its various options by involving themselves in a person-centred, semi-structured training programme. This role of SOCHARA/ CHC is being further consolidated, and CHC is evolving into a research and educational centre in community health, public health and health policy.

The other area in which SOCHARA/CHC has been greatly involved is in building a people’s movement in health. The SOCHARA/ CHC review had also suggested that CHC utilize its network and relationships built over the years to contribute to a mass movement in health. This came true in 2000 A.D., with the Indian Health Assembly held in Calcutta, India and the first People’s Health Assembly (PHA-1) being held in Savar, Bangladesh in December 2000. CHC contributed in mobilizing people and organisations, and in conducting both these assemblies. CHC was also deeply involved in the formation of the People’s Health Movement (PHM) and in drafting of the People’s Charter for Health.

In 2002 two years after the first PHA, PHM secretariat was shifted from GK, Savar to the PHM India region, and CHC was asked to host it on behalf of region. Ravi Narayan is currently the co-ordinator of the PHM Secretariat (Global) based at CHC, Bangalore. The People’s Health Movement has come a long way, and five years after its formation, is getting ready to host the second People’s Health Assembly (PHA-2) at Cuenca, Ecuador in July 2005.

To know more about SOCHARA/CHC, get in touch with us, or email Thelma Narayan, the co-ordinator of CHC.

Naveen I. Thomas, Health Policy Fellow, CHC (June 2005)