Community Health – Christian Contribution to Primary Health Care

1. Community Health – Christian Contribution to Primary Health Care Jack Bryant CCIH Conference Bishop Claggett Center, Buckeystown, MD May 24, 2008

2. Agenda • Reflection on Carl Taylor’s contributions. • How I became involved in this field – and it changed my life! • The Quest for Health and Wholeness. • Christian Medical Commission—its founding and response to WHO’s call for new perspectives on health and well-being. 1970s • Primary Health Care – CMC contribution to WHO’s new approach to Health and Development. 1970s

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

4. Pre-Alma Ata • Challenge to International Agencies – article written by Carl Taylor, 1975. • Five Principles Underlying the New International Style • Ten Guidelines for Practical Implementation • Conclusion: What kind of world do we want? I close with a quality of life question that is intermeshed with many basic moral and philosophical issues. Are affluent countries coming to the point where we will have to choose what not to have and what not to do, rather than continuing to monopolize a disproportionate share of the world’s goods?

5. Pre-Alma Ata • I close with a quotation from Martin Luther King: “Through your scientific genius, you have made a world a neighborhood but you have as yet failed to employ your moral and spiritual genius to make of it a brotherhood.” • This is our Challenge!

6. Pre-Alma Ata – the Churches • JB, then working in Thailand, called by Philip Potter, World Council of Churches, to meet in Copenhagen, 1967. John Karefa Smart, important leader in Sierra Leon, also present. • Concern for instability of 1200 mission hospitals in newly independent countries. • What to do about those hospitals? • Response: Wrong Question. Concern should reach beyond hospitals to focus on how to provide health care for the people, including those who cannot reach the hospitals.

7. Pre-Alma Ata – the Churches • Potter: Who knows how to provide such health care for all the people? • Bryant: There are many who are working at it. Let us seek their advice. • Potter: Yes. Let us bring them together. • Result: The founding of the Christian Medical Commission. • The CMC became a major player in the thinking and actions related to Alma Ata and PHC. Bryant and Taylor early participants.

8. The Quest for Health and Wholeness • The Quest for Health and Wholeness, 1981. • James C. McGilvray, Director, Christian Medical Commission – CMC. Brilliant, thoughtful, committed leadership. • This fine book tells the story of events, and inquiries into Christian perspectives, values, and concerns that led to the founding of the Christian Medical Commission. • German Institute for Medical Missions, Tubingen, Germany -- continuous support of the CMC, before and after its founding • Two meetings of critical importance to the founding and support of CMC were Tubingen I, 1964 and Tubingen II, 1967.

9. The Quest for Health and Wholeness • This book describes only a segment of this QUEST. Its content is determined by the experience of a group of people variously related to the promotion of health and/or to the practice of medicine who were drawn together at various times by their Christian commitment and desire to understand the relationship between health, wholeness and salvation and what this understanding, however tentative, would say to the Churches’ involvement in medical mission.

10. The Quest • For some, the search for the meaning of health was first prompted by an involvement in evaluating the contribution of Western medicine to the health care of populations in lesser developed countries. • It began with surveys of church-related medical programs in several African and Asian countries in order to measure their effectiveness in meeting the health needs of the people and, also, their appropriateness as expressions of a Christian ministry of healing.

11. The Quest • From the surveys, it was found that the churches had concentrated their efforts on building and operating hospital and clinic-based curative services, which had limited impact on the problems. • They were, basically, repair facilities which did little if anything to remove the causes of sickness or to promote and maintain health.

12. The Quest • While they were necessary components of a medical care system, their relevance was diminished because of the absence or paucity of other components of a medical care system, such as public health measures, primary health facilities, etc., • and their operating costs were so high, relative to the resources, that the possibility of meeting more basic health needs was precluded.

13. The Quest • Moreover, these church-related institutions, together with all the other available facilities of Western medicine, were reaching only 20% of the populations in these countries, • so that 80%, and these were usually the poorest and most needy, were deprived of services other than traditional forms of healing when these were available. • The obvious disparity between those served and those deprived of medical services challenged the priority, long practiced in Western medicine, of individual care on a one-to-one basis.

14. The Quest • Human life has a social dimension as well as a personal core, and while medicine must be person-oriented rather than disease-oriented it can never neglect the social relationships and demands which shape the person. • This led to the formulation of community medicine – a system designed to bring the benefits of medical care in an acceptable manner to as many as possible. • This was later amended to correct the imbalanced relationship between professionals and those who bore the burden of sickness, so that the latter fully participated in the development of the system of care and in the therapy itself.

15. The Quest • David Jenkins, Professor and Head, Department of Religious Studies, University of Leeds. • Foreword to the Quest for Health and Wholeness • If, therefore, we have faith, hope and compassion we are launched on a Quest. • This is a quest for new ways of responding practically and hopefully to the continuing evidences and experiences of human sickness and disease.

16. The Quest • If one is a Christian or a sympathiser who is seeking for a fresh vision of what Christianity, at its heart, has pointed to or might point to, then the quest is at the same time a quest for a renewed and effective understanding of the presence of God and of what He offers through a re-shaped and re-invigorated fellowship or church.

17. The Quest • Thus it will be found that the account which follows naturally contains a number of strands. There is a search for effective contemporary ways of understanding and sharing the Christian Gospel. There is a search for new forms of expressing and being the Church in local service and in worldwide witness.

18. The Quest • The book which follows is an account of how some people, who are committed to Christianity and committed to the practice of medicine, have tried to face contemporary realities which call both into question. • The questions which are posed, the criticisms which have to be faced, and the problems which have to be solved, emerge as the account proceeds. • All that needs to be pointed out in a Foreword is that the search described began from, and continues to be sustained by, convictions about the truth inherent in the Christian Gospel.

19. Dr. Robert Lambourne • From his reports emerged disturbing picture of the manner in which modern care was at odds with the quest for health & wholeness. • The growth of medical specialization has tended to break down the patient into pathological parts so that less and less is he regarded or treated as a whole patient. • Technology and research…dehumanize what should be a very personal approach. The results of a battery of tests becomes more important than the relationship of persons in a therapeutic encounter. Translated into institutional form, the hospital becomes a factory for repair of things rather than as a hospice for the care of souls.

20. Perspectives on Health and Healing • J. Bryant, Chairman of CMC, addressed the question of “health care and justice”. • He applied the notions of “entitlement”, “natural rights”, and “positive rights”, and developed some tentative principles:’ • Whatever health services are available should be equally available to all. Departures from that equality of distribution are permissible only if those worst off are made better off.

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

22. Tubingen I • 1963 – Division of World Mission and Evangelism of the World Council of Churches and the Commission on World Mission of the Lutheran World Federation – decided to sponsor a consultation which would address itself to these issues. • In a proposal for such a consultation these bodies reiterated their firm belief that there is a Christian understanding of the meaning of health and the means of healing which forms an essential part of the contribution of a Christian medical service. • God’s purpose for the redemption of man as proclaimed in the Gospel of Jesus Christ is contained in acts that restore man to the wholeness of his life.

23. Tubingen I • Man is not himself aware of the real nature of the sickness that infects him – body, mind, spirit. God in human form brings new being to man, restores him to fellowship with himself, offers him hope in the world, and calls him to a service in the world which he as redeemed and healed man can do in gratitude for God’s supreme act of salvation. • So, the purpose of the consultation was set. It was to explore this claim to uniqueness in the Christian understanding of health and healing. • It also had a pragmatic objective to explore that need for new missionary strategy and planning.

24. Tubingen I • The Findings clearly indicate the unanimous opinion of the participants that the Church does have a specific task in the field of health which arises from its place in the whole Christian belief about God’s plan of salvation for mankind. • Whether in the desperate squalor of overpopulated and underdeveloped areas, or in the spiritual wasteland of affluent societies, it is a sign of God’s victory and a summons to his service. • The participants expressed their regret that there was so little evidence in theological education of concern for or explicit teaching about the Christian understanding of healing.

25. Tubingen II • 1967, again held at the German Institute for Medical Mission, Tubingen, Germany. • An introduction attempted to state the problems and pressures generated by contemporary health and medical services – that while, in varying degrees, man lives longer than he used to; his stay in the hospital is shorter and he has a much greater hope of recovery from diseases which were once considered fatal; in the process, he has been reduced to an impersonal object. Because of the focus on his localized pathology, he tends to lose his identity and individual uniqueness.

26. Tubingen II • Fortunately, the Christian faith is not dependent on its institutions or professionals. The gospel still proclaims a God of love and justice who overwhelms all technologies and offers a quality of life which alone can provide that health and wholeness (salvation) which is God’s intent for his people. • And for those who cannot fathom the mysteries of theological formulations, there still remains the invitation of Christ himself.

27. Tubingen II • Come, enter and possess the kingdom that has been ready for you since the world was made. For when I was hungry you gave me food; when thirsty, you gave me drink; when I was a stranger you took me into your home, when naked you clothed me; when I was ill you came to my help, when in prison you visited me…I tell you this, anything you did for one of my brothers here, however humble, you did for me. (St. Matth. 25L34-36m 40)

28. Critical Community-Based Experiences. • 1972 – WHO/UNICEF Joint Committee on Health Policy prepared a document on “Alternative Approaches to Meeting the Basic Health Needs of Populations in Developing Countries”. • WHO called for reports of promising projects. • CMC responded accordingly and identified three projects, each of which offered important lessons among alternative approaches.

29. Critical Community-Based Experiences. • First, 1967, McGilvray “discovered” a project in Indonesia run by Dr. and Mrs. (Dr.) Gunawan Nugroho. Initiated 1963, and featured such innovations as goat and chicken farming to increase the income available to the poorest members of the community and the creation of a health fund that aimed at providing inexpensive treatment so that anyone who was sick could afford to seek medical care.

30. Critical Community-Based Experiences. • In addition to curative and preventive services, a community health program should “place greater emphasis on activities that increase the potential of man to live healthily. Educational activities aimed at the dissemination of lucid information about health and nutrition, the spread of disease and its consequences, the responsibility of a patient towards the general community and his own milieu, family health, and family planning are the basis of a community health program.

31. Critical Community-Based Experiences. • Second – also run by a husband-wife medical team, Mabelle and Rajanikant Arole. • Their project developed in Jamkhed India was supported by the CMC. They described in 1970 how their intitial attempts at providing curative services “had done little for the general health of the community around us”. • They left India to go to Johns Hopkins University to study public health where they were directly influenced by the works of several members of the CMC, particularly Carl Taylor.

32. Critical Community-Based Experiences. • The Jamkhed Project, as conceived at Johns Hopkins, aimed to establish a viable and effective health care system that involved the community in “decision-making”, was “planned at the grass roots”, used local resources “to solve local health problems,” and provided “total care, not fragmented care.” • Raj Arole presented the Jamkhed Project to the 1972 CMC annual meeting. Since then, the Jamkhed Project has become an international training center. (Connie Gates, here today, has a major role)

33. Critical Community-Based Experiences. • Third, Carroll Behrhorst directed the Chimaltenango development project in Guatemala, the third project to be included in Health by the People. (Ken Newell, WHO). • The use of community health promoters was one of the major features of this project. Selected by the communities and often with a limited education, promoters were trained “to recognize and alleviate common medical problems.”

34. Critical Community-Based Experiences. • But treating diseases ranked 7th on the list of priorities as judged by the local Indian population. Their list was headed by: 1. Social and economic injustice. 2. Land tenure. 3. Agricultural production and marketing, and 4. Population control, leading Behrhorst to conclude: • The truly successful public health program among the rural poor must tackle basic problems of economic and political development. This by no means indicates that program leaders should plunge into controversial national issues or ally themselves with specific political movements.

35. Critical Community-Based Experiences. • A program must be detached from factional politics if it is to respond to the people without power. Yet, there are levels below those of national politics where the people can learn to control their own lives through politics and economics. A cooperative is a good example, since it responds to financial need and builds local leadership. • Behrhost presented his project at the 1973 CMC annual meeting.

36. PHC: WHO’s New Approach to Health Development • The relationship between the CMC and WHO has been portrayed in terms of an anecdotal story involving Halfdan Mahler, WHO Director General, and Nita Barrow, Deputy Director of the CMC. • When invited in 1974 to introduce the CMC’s approach to comprehensive health care to the staff of WHO, she responded, “But this is like David and Goliath,” to which Mahler replied, “Yes, but I am a parson’s son and I know what David did to Goliath.”

37. PHC: WHO’s New Approach to Health Development • The most significant result of this cooperation between the two organizations – WHO and CMC -- was the formulation of the principles of Primary Health Care, which were absorbed by the leadership of WHO. • The Executive Board of WHO identified issues of critical importance: • a) shape PHC around the life patterns of the population; • b) involve the local population; • c) place a maximum reliance on available community resources;

38. PHC: WHO’s New Approach to Health Development • d) provide for an integrated approach of preventive, curative and promotive services for both the community and the individual; • e) provide for all interventions to be undertaken “at the most peripheral practicable level of the health services by the worker most simply trained for this activity”; • f) provide for other echelons of services to be designed in support of the needs of the peripheral level; and • g) be “fully integrated with other sectors involved in community development.”

39. PHC: WHO’s New Approach to Health Development • Four general courses of national action were outlined with the expectation that each country would respond to the need in a unique manner. These were: • 1) the development of a new tier of PHC; • 2) the rapid expansion of existing health services with priority being given to PHC; • 3) the reorientation of existing health services so as to establish a unified approach to PHC; • 4) making maximum use of ongoing community activities, especially develop-mental ones, for the promotion of PHC.

40. PHC: WHO’s New Approach to Health Development • The CMC, along with other NGOs with similar policies, provided those responsible for PHC within WHO with an exciting outlet of creative activity, one that deserves to be revisited by those today who are concerned with community health development.

41. Reflections on the CMC • There is no doubting the contributions of the CMC: • Its focus on health care systems in need of extensive change. • Its bringing together persons from both diverse religious groups and Churches, with WHO, to focus on health care needs in poor countries. • Its provision of examples of community-based health care, particularly applicable to less developed countries. • Its subsequent reflections on fresh perspectives of both theology and health.

42. Alma Ata -- 1978 • One of the great events in the history of public health. • U.S. Delegation – Julius Richmond, Surgeon General; Carl Taylor, Jack Bryant, Peter Bell, Ted Kennedy. • Influenced the professional lives of us all. • Bryant was then a staff person with President Jimmy Carter, and served on the Executive Board of WHO, thereby immersed in global health issues.

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

44. 10th Anniversary of Alma-Ata, RIGA, USSR, 1988 • Reflecting on a decade of action and inaction related to PHC. It was clear that not enough was being done, and there was an insistent call for new forms of analysis, partnerships and new mechanisms of action. • Mahler: “We must have an obsession, a moral obsession, about the least developed countries. They are missing out totally in the development process. It is development gone wrong.”

45. WHO’s Role • In a December 2003 article in the Lancet, WHO Director General, Lee wrote: • A crucial part of justice in human relations is promotion of equitable access to health-enabling conditions. The Alma-Ata goal of Heath for All was right. So were the basic principles of primary health care: equitable access, community participation, and intersectoral approaches to health improvement. These principles must be adapted to today’s context.

46. After Alma-Ata • In this complex world, there have been numerous perspectives on health and development, some positive and consistent with Alma-Ata, others reaching into other sectors and values. • Here is a listing of the major perspectives and processes of the 30 years since Alma-Ata

47. Changing Perspectives on PHC and Development • Social Determinants of Health • Selective PHC • Neoliberalism • Globalization • Commission on Macroeconomics and Health • Millennium Development Goals • PAHO – values, principles, elements of PHC • WHO’s new Director General – Dr. Margaret Chan

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

49. Onward with the Chapter • Bryant visited WHO-Geneva, 2007. • Meetings with Halfdan Mahler, Mirta Roses Periago, staff of Margaret Chan. • There was interest in the Alma-Ata Chapter. • Meanwhile, WHO/PAHO were responding to Margaret Chan’s commitment to Primary Health Care…planned a Conference on PHC and the MDGs, Buenos Aires, August, 2007 • Bryant, do join us for this important event! And he did!

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