964 Hamilton Avenue
Palo Alto, California 94301, USA
International Hospital Federation Congress
Sessions on Health Auxiliaries and the Health Team
22 - 27 May, 1977
THE VILLAGE HEALTH WORKER --LACKEY OR LIBERATOR?
-- David Werner --
Throughout Latin America, the programmed use of health auxiliaries has, in recent years, become an important part of the new international push of 'community oriented' health care. But in Latin America village health workers are far from new. Various religious groups and non-government agencies have been training promotores de salud or health promoters for decades. And to a large (but diminishing) extent, villagers still rely, as they always have, on their local curanderos, herb doctors, bone setters, traditional midwives and spiritual healers. More recently, the médico practicante or empirical doctor has assumed in the villages the same role of self-made practitioner and prescriber of drugs that the neighborhood pharmacist has assumed in larger towns and cities.
Until recently, however, the respective Health Departments of Latin America have either ignored or tried to stamp out this motley work force of nonprofessional healers. Yet the Health Departments have had trouble coming up with viable alternatives. Their Western-style, city-bred and city-trained M.D.s not only proved uneconomical in terms of cost effectiveness; they flatly refused to serve in the rural area.
The first official attempt at a solution was, of course, to produce more doctors. In Mexico the National University began to recruit 5000 new medical students per year (and still does so). The result was a surplus of poorly trained doctors who stayed in the cities.
The next attempt was through compulsory social service. Graduating medical students were required (unless they bought their way off) to spend a year in a rural health center before receiving their licenses. The young doctors were unprepared either by training or disposition to cope with the health needs in the rural area. With discouraging frequency they became resentful, irresponsible or blatantly corrupt.
Next came the era of the mobile clinics. They, too, failed miserably. They created dependency and expectation without providing continuity of service. The net result was to undermine the people's capacity for self care.
It was becoming increasingly clear that provision of health care in the rural area could never be accomplished by professionals alone. But the medical establishment was--and still is--reluctant to crack its legal monopoly.
At long last, and with considerable financial cajoling from foreign and international health and development agencies, the various health departments have begun to train and utilize auxiliaries. Today, in countries where they have been given half a chance, auxiliaries play an important role in the health care of rural and periurban communities. And if given a whole chance, their impact could be far greater. But, to a large extent, politics and the medical establishment still stand in the way.
* * * * *
My own experience in rural health care has mostly been in a remote mountainous sector of Western Mexico, where, for the past 12 years I have been involved in training local village health workers, and in helping foster a primary health care network, run by the villagers themselves. As the villagers have taken over full responsibility for the management and planning of their program, I have been phasing out my own participation to the point where I am now only an intermittent advisor. This has given me time to look more closely at what is happening in rural health care in other parts of Latin America.
Last year a group of my co-workers and I visited nearly 40 rural health projects, both government and non-government, in nine Latin American countries (Mexico, Guatemala, Honduras, E1 Salvador, Nicaragua, Costa Rica, Venezuela, Colombia and Ecuador). Our objective has been to encourage a dialogue among the various groups, as well as to try to draw together many respective approaches, methods, insights and problems into a sort of field guide for health planners and educators, so we can all learn from each other's experience. We specifically chose to visit projects or programs which were making significant use of local, modestly trained health workers or which were reportedly trying to involve people more effectively in their own health care.
We were inspired by some of the things we saw, and profoundly disturbed by others. While in some of the projects we visited, people were in fact regarded as a resource to control disease, in others we had the sickening impression that disease was being used as a resource to control people. We began to look at different programs, and functions, in terms of where they lay along a continuum between two poles: community supportive and community oppressive.
Community supportive programs or functions are those which favorably influence the long-range welfare of the community, that help it stand on its own feet, that genuinely encourage responsibility, initiative, decision making and self-reliance at the community level, that build upon human dignity.
Community oppressive programs or functions are those which, while invariably giving lip service to the above aspects of community input, are fundamentally authoritarian, paternalistic or are structured and carried out in such a way that they effectively encourage greater dependency, servility and unquestioning acceptance of outside regulations and decisions; those which in the long run are crippling to the dynamics of the community.
It is disturbing to note that, with certain exceptions, the programs which we found to be more community supportive were small non-government efforts, usually operating on a shoestring and with a more or less sub-rosa status.
As for the large regional or national programs-- for all their international funding, top-ranking foreign consultants and glossy bilingual brochures portraying community participation--we found that when it came down to the nitty-gritty of what was going on in the field, there was usually a minimum of effective community involvement and a maximum of dependency-creating handouts, paternalism and superimposed, initiative destroying norms.
I don't have time to elaborate here, but anyone who is interested in a more detailed account of community supportive and oppressive health programming may send for a copy of a paper I presented in England last year entitled "Health Care and Human Dignity."
In our visits to the many rural health programs in Latin America, we found that primary health workers come in a confusing array of types and titles. Generally speaking, however, they fall into two major groups:
or health technician
or village health workers
In addition to the health workers just described, many Latin American countries have programs to provide minimal training and supervision of traditional midwives. Unfortunately, Health Departments tend to refer to these programs as 'Control de Parteras Empíricas'--Control of Empirical Midwives--a terminology which too often reflects an attitude. Thus to Mosquito Control and Leprosy Control has been added Midwife Control. (Small wonder so many midwives are reticent to participate!) Once again, we found the most promising work with village midwives took place in small non-government programs. In one such program (in Pinalejo, Honduras) the midwives had formed their own club and organized trips to hospital maternity wards to increase their knowledge.
* * * * *
What skills can the village health worker perform? How well does he perform them? What are the limiting factors that determine what he can do. These were some of our key questions when we visited different rural health programs.
We found that the skills which village health workers actually performed varied enormously from program to program. In some, local health workers with minimal formal education were able to perform with remarkable competence a wide variety of skills embracing both curative and preventive medicine as well as agricultural extension, village cooperatives and other aspects of community education and mobilization. In other programs--often those sponsored by Health Departments--village workers were permitted to do discouragingly little. Safeguarding the medical profession's monopoly on curative medicine by using the standard argument that prevention is more important than cure (which it may be to us but clearly is not to a mother when her child is sick) instructors often taught these health workers fewer medical skills than many villagers had already mastered for themselves. This sometimes so reduced the people's respect for their health worker that he (or usually she) became less effective, even in preventive measures.
In the majority of cases, we found that external factors, far more than intrinsic factors, proved to be the determinants of what the primary health worker could do. (See Outline 1.) We concluded that the great variation in range and type of skills performed by village health workers in different programs has less to do with the personal potentials, local conditions or available funding than it as to do with the preconceived attitudes and biases of heath program planners, consultants and instructors. In spite of the often repeated eulogies about "primary decision making by the communities themselves," seldom do the villagers have much, if any, say in what their health worker is taught and told to do.
The limitations and potentials of the village health worker--what he is permitted to do and, conversely, what he could do if permitted--can best be understood if we look at his role in its social and political context. In Latin America, as in many other parts of the world, poor nutrition, poor hygiene, low literacy and high fertility help account for the high morbidity and mortality of the impoverished masses. But as we all know, the underlying cause--or more exactly, the primary disease--is inequity: inequity of wealth, of land, of educational opportunity, of political representation and of basic human rights. Such inequities undermine the capacity of the peasantry for self care. As a result, the political/economic powers-that-be assume an increasingly paternalistic stand, under which the rural poor become the politically voiceless recipients of both aid and exploitation. (See Figure 3.) In spite of national, foreign and international gestures at aid and development, in Latin America the rich continue to grow richer and the poor poorer. As anyone who has broken bread with villagers or slum dwellers knows only too well: health of the people is far more influenced by politics and power groups, by distribution of land and wealth, than it is by treatment or prevention of disease.
Political factors unquestionably comprise one of the major obstacles to a community supportive program. This can be as true for village politics as for national politics. However, the politico-economic structure of the country must necessarily influence the extent to which its rural health program is community supportive or not.
Let us consider the implications in the training and function of a primary health worker:
If the village health worker is taught a respectable range of skills, if he is encouraged to think, to take initiative and to keep learning on his own, if his judgment is respected, if his limits are determined by what he knows and can do, if his supervision is supportive and educational, chances are he will work with energy and dedication, will make a major contribution to his community and will win his people's confidence and love. His example will serve as a role model to his neighbors, that they too can learn new skills and assume new responsibilities, that self?improvement is possible. Thus the village health worker becomes an internal agent-of-change, not only for health care, but for the awakening of his people to their human potential. . . and ultimately to their human rights.
However, in countries where social and land reforms are sorely needed, where oppression of the poor and gross disparity of wealth is taken for granted, and where the medical and political establishments jealously covet their power, it is possible that the health worker I have just described knows and does and thinks too much. Such men are dangerous: They are the germ of social change.
So we find, in certain programs, a different breed of village health worker is being molded . . . one who is taught a pathetically limited range of skills, who is trained not to think, but to follow a list of very specific instructions or 'norms', who has a neat uniform, a handsome diploma and who works in a standardized cement block health post, whose supervision is restrictive and whose limitations are rigidly predefined. Such a health worker has a limited impact on the health and even less on the growth of the community. He--or more usually she--spends much of her time filling out forms.
* * * * *
In a conference I attended in Washington last December, on Appropriate Technology in Health in Developing Countries, it was suggested that "Technology can only be considered appropriate if it helps lead to a change in the distribution of wealth and power." If our goal is truly to get at the root of human ills must we not also recognize that, likewise, health projects and health workers are appropriate only if they help bring about a healthier distribution of wealth and power?
Factors that Influence What a Primary Health Worker Can Do
Factors influencing personal potential of VHW
Outside decisions and control
What the health worker can do is too often limited by external factors (doctors and politics) rather than determined by his personal capabilities and potential.
Fig. 3 Too often aid and exploitation go hand in hand.
We say prevention is more important than cure. But how far are we willing to go? Consider diarrhea:
Each year millions of peasant children die of diarrhea. We tend to agree that most of these deaths could be prevented. Yet diarrhea remains the number one killer of infants in Latin America and much of the developing world. Does this mean our so?called 'preventive' measures are merely palliative? At what point in the chain of causes which makes death from diarrhea a global problem (see Outline #2) are we coming to grips with the real underlying cause. Do we do it . . .
- by preventing some deaths through treatment of diarrhea?
- by trying to interrupt the infectious cycle through construction of latrines and water systems?
- by reducing high risk from diarrhea through better nutrition?
- or by curbing land tenure inequities through land reform?
Land reform comes closest to the real problem. But the peasantry is oppressed by far more inequities than those of land tenure. Both causing and perpetuating these crushing inequities looms the existing power structure: local, national, foreign and multinational. It includes political, commercial and religious power groups as well as the legal profession and the medical establishment. In short it includes . . . ourselves.
As the ultimate link in the causal chain which leads from the hungry child with diarrhea to the legalized inequities of those in power, we come face to face with the tragic flaw in our otherwise human nature, namely greed.
Where, then, should prevention begin? Beyond doubt, anything we can do to minimize the inequities perpetuated by the existing power structure will do far more to reduce high infant mortality than all our conventional preventive measures put together. We should, perhaps, carry on with our latrine building rituals, nutrition centers and agricultural extension projects. But let's stop calling it prevention. We are still only treating symptoms. And unless we are very careful, we may even be making the underlying problem worse . . . through increasing dependency on outside aid, technology and control.
But this need not be the case. If the building of latrines brings people together and helps them look ahead, if a nutrition center is built and run by the community and fosters self-reliance, and if agricultural extension, rather than imposing outside technology encourages internal growth of the people toward more effective understanding and use of their land, their potentials and their rights . . . then, and only then, do latrines, nutrition centers and so-called extension work begin to deal with the real causes of preventable sickness and death.
This is where the village health worker comes in. It doesn't matter much if he spends more time treating diarrhea than building latrines. Both are merely palliative in view of the larger problem. What matters is that he get his people working together.
Yes, the most important role of the village health worker is preventive. But preventive in the fullest sense, in the sense that he help put an end to oppressive inequities, in the sense that he help his people, as individuals and as a community, liberate themselves not only from outside exploitation and oppression, but from their own short-sightedness, futility and greed.
The chief role of the village health worker, at his best, is that of liberator. This does not mean he is a revolutionary (although he may be pushed into that position). His interest is the welfare of his people. And, as Latin America's blood-streaked history bears witness, revolution without evolution too often means trading one oppressive power group for another. Clearly, any viable answer to the abuses of man by man can only come through evolution, in all of us, toward human relations which are no longer founded on short-sighted self-interest, but rather on tolerance, sharing and compassion.
I know it sounds like I am dreaming. But the exciting thing in Latin America is that there already exist a few programs that are actually working toward making these things happen--where health care for and by the people is important, but where the main role of the primary health worker is to assist in the humanization or, to use Paulo Freire's term, conscientización of his people.
Before closing let me try to clear up some common misconceptions.
Many persons still tend to think of the primary health worker as a temporary second-best substitute for the doctor . . . that if it were financially feasible the peasantry would be better off with more doctors and fewer primary health workers.
I disagree. After twelve years working and learning from village health workers--and dealing with doctors--I have come to realize that the role of the village health worker is not only very distinct from that of the doctor, but, in terms of health and well-being of a given community, is far more important. (See appendix.)
You may notice I have shied away from calling the primary health worker an 'auxiliary'. Rather I think of him as the primary member of the health team. Not only is he willing to work on the front line of health care, where the needs are greatest, but his job is more difficult than that of the average doctor. And his skills are more varied. Whereas the doctor can limit himself to diagnosis and treatment of individual 'cases', the health worker's concern is not only for individuals--as people--but with the whole community. He must not only answer to his people's immediate needs, but he must also help them look ahead, and work together to overcome oppression and to stop sickness before it starts. His responsibility is to share rather than hoard his knowledge, not only because informed self-care is more health conducing than ignorance and dependence, but because the principle of sharing is basic to the well-being of man.
Perhaps the most important difference between the village health worker and the doctor is that the health worker's background and training, as well as his membership in and selection by the community, help reinforce his will to serve rather than bleed his people. This is not to say that the village health worker cannot become money-hungry and corrupt. After all, he is as human as the rest of us. It is simply to say that for the village health worker the privilege to grow fat off the illness and misfortune of his fellow man has still not become socially acceptable.
||The primary health worker lives and works at the level of the people. His first job is to share his knowledge.
(Illustration from the forthcoming English edition of Where There is No Doctor by David Werner)
Forgive me if I seem a little bitter, but when you live with and share the lot of Mexican villagers for 12 years, you can't help but feel a little uncomfortable about the exploits of the medical profession. For example, Martin, the chief village medic and coordinator of the villager run health program I helped to start, recently had to transport his brother to the big city for emergency surgery. His brother had been shot in the stomach. Now Martin, as a village health worker supported through the community, earns 1,600 pesos ($80.00) a month, which is in line with what the other villagers earn. But the surgeon charged 20,000 pesos ($1000.00) for two hours of surgery. Martin is stuck with the bill. That means he has to forsake his position in the health program and work for two months as a wet-back in the States--in order to pay for two hours of the surgeon's time. Now, is that fair?
* * * * *
No, the village health worker, at his best, is neither choreboy nor auxiliary nor doctor's substitute. His commitment is not to assist the doctor, but to help his people.
The day must come when we look at the primary health worker as the key member of the health team, and at the doctor as the auxiliary. The doctor, as a specialist in advanced curative technology, would be on call as needed by the primary health worker for referrals and advice. He would attend those 2-3% of illnesses which lie beyond the capacity of an informed people and their health worker, and he even might, under supportive supervision, help out in the training of the primary health worker in that narrow area of health care called Medicine.
Health care will only become equitable when the skills pyramid has been tipped on its side, so that the primary health worker takes the lead, and so that the doctor is on tap and not on top.
TIPPING THE HEALTH MANPOWER PYRAMID ON ITS SIDE
COMPARISON OF THE MEDICAL DOCTOR AND THE PRIMARY HEALTH WORKER
(Note: The medical doctor as described here is the typical Western-style M.D. as produced by medical schools in Latin America. Clearly, there are exceptions. Most Latin American medical schools are beginning to modify their curricula to place greater emphasis on community health. However, not modifications but radical changes, both in selection and training, are needed if doctors are ever to become an integrated and fully positive part of a health team that serves all the people.)
|CONVENTIONAL DOCTOR||VILLAGE HEALTH WORKER (at his best)|
|Usually upper middle class||From the peasantry.|
|How chosen||By medical school for:
grade point average;
economic and social status.
|By community for:
interest, compassion, knowledge of community, etc.
Training concentrates on:
Limited, key training appropriate to serve all the people in a given community:
Individual patient oriented
Seeks a balance between curative and preventive. (Curative to meet felt needs,
preventive to meet real
|Primary Job Interest||The challenging and interesting cases. (Often bored by day to day problems.)||Helping people resolve their biggest problems because he is their friend and neighbor.|
|Attitude toward the sick||Superior. Treats people as patients. Turns people into 'cases'
Underestimates people's capacity for self-care.
|On their level. Treats patients as people.
Mutual concern and interest because the VHW is village selected.
|Attitude of the sick toward M.D. or VHW||Hold him in awe. Blind trust (or sometimes distrust).||See him as a friend. Trust him as a person, but feel free to question him.
Mutual concern and interest because the VHW is village selected.
|How does he use Medical knowledge?||Hoards it.
Delivers 'services', discourages self-care, keeps patients helpless and dependent.
Encourages informed self-care, helps the sick and family understand and manage problems.
Often inaccessible, especially to poor.
Lives right in village.
Low charges for services.
Treats everyone equally and as his equal.
|Consideration for economic factors||Overcharges.
factors high earnings.
Feels it is his God-given
right to live in luxury
while others hunger.
Often prescribes unnecessarily costly drugs.
|Relative Permanence||At most spends 1-2 years in a
rural area and then moves
to the city.
|A permanent member of the community.|
|Continuity of Care||Can't follow up cases because he doesn't live in the isolated areas.
||Visits his neighbors in their homes to make sure they get better and learn how not to
get sick again.
Too expensive to ever meet
Low cost of both training and practice.
|Resource Requirements||Hospital or health center.
Depends on expensive, hard-to-get equipment and a large subservient staff to work at full potential.
|Works out of home or simple structure.
People are the main resource.
|Present Role||On top.
Directs the health team.
Manages all kinds of medical problems, easy or complex.
Often overburdened with easily treated or preventable illness.
|On the bottom.
Often given minimal responsibility, especially in medicine.
Regarded as an auxiliary
( lackey) to the physician.
|Impact on the Community||Relatively low (in part
Sustains class differences,
mystification of medicine,
dependency on expensive
Drains resources of poor
|Appropriate (future?) Role||On tap (not on top).
Functions as an auxiliary to the VHW, helping to teach him more medical skills and attending referrals at the VHW's request. (The 2-3% of cases that are beyond the VHW's limits.)
He is an equal member of the health team.
|Recognized as the key member of the health team.
Assumes leadership of health care activities in his village, but relies on advice, support, and referral assistance from the doctor when he needs it.
He is the doctor's equal (although his earnings remain in line with those of his fellow villagers).
TWO APPROACHES TO HEALTH CARE
VILLAGE HEALTH WORKERS
CAN HELP DOCTORS LEARN
THE SECOND APPROACH