The Value Of Modestly Trained Health Workers

“What’s been killing our babies is modern medical care.”

by David Werner

January 2008

In an exchange visit to the Philippines several years ago, our group of village health workers from Latin America visited the Makapawa Community Health Program in an impoverished rural area on the outskirts of Tacloban city. The local health promoters, who were themselves villagers, took us to see their growth monitoring (baby weighing) activity, for children under five. Proudly they told us that since they’d begun three years before, fewer children were dangerously underweight and child mortality had dropped by nearly half. We asked why. The health promoters said they thought it was because of all the information about good nutrition they gave mothers when they weighed their babies. But the mothers present said they’d heard it all before. Visiting nurses and health authorities had been coming to their village for years, lecturing them about good nutrition. “If we’re not feeding our children as we should,” said the mothers, “it’s not because we don’t know what foods they need. It’s because we can’t afford them!”

Nevertheless, the mothers agreed that since the village health program had begun, their children were plumper and fewer were dying. But no one had a clear answer as to why. Wages, if anything, were lower.

So we moved on to observe another activity: collective preparation of traditional medicines. With the help of the health promoters, small groups of mothers came together once a week to prepare “home remedies” for common illnesses, using native herbs and fruit. They concocted everything from cough syrups, to worm medicines, to oral rehydration drinks for diarrhea. They made skin ointments for scabies and ringworm by mixing sulfur with vinegar. While these remedies were mostly based on ancient folk cures, the Makapawa team had carefully selected, and sometimes modified, them to be sure they had scientific efficacy and that the benefits outweighed the risks. For example, the rehydration drink contained juices of guava and other plants, but care was taken to insure the correct balance of sugar and salt to best combat dehydration.

One mother explained to us that since they’d rediscovered the use of homemade folk remedies, they no longer had to spend as much money traveling to doctors in the cities, paying for expensive consultation, and buying expensive drugs in the pharmacies. “That saves us a bunch of money!”

Then another mother said, “Now I know why our children are better fed and dying less now! It’s because a lot of the money we used to spend on costly doctors and medicines, we can now spend on food. So our children have more to eat.”

Everybody nodded in agreement. “Do you realize what we’re saying?” said an elderly woman. “We’re saying that what’s been killing our babies is modern medical care – because of its high costs!” (For a more detailed account of this Philippine exchange see Helping Health Workers Learn, Chap 18,)

This disturbing discovery by mothers in the Philippines is not an isolated case. Studies in many poor countries have shown that poor families often spend 30% or more of their income on health care related expenses. Furthermore, the ever-rising cost of professional medical services, together with the elevated cost of potentially life-saving pharmaceuticals, deprive a large segment of humanity from the health services they need. For many, the high cost of health care is a death sentence. This is especially true for the half of humanity that earns less than two dollars a day.

Observations by the World Bank, WHO, Oxfam, and others have shown that the major factor that drives low-income families into absolute destitution, from which they never recover, is the crushing cost of medical expenses. Around the world, families are made to choose between medical services and food. Once they fall into debt to loan sharks for their medical bills, a vicious cycle of hunger, illness, and spiraling expenses does them in.

This is, of course, an argument for socialized medicine – or at least for some kind of progressive health plan that makes sure everyone’s basic health needs are humanely met. But with today’s private-profit oriented global economy, little is left of the left. Rather than resolving this Tantalus-like paradox of unreachable healthcare, recent socioeconomic trends are marginalizing the poor even more. As giant corporations gain ever-stronger control over national and global decision-making, the gap between the haves and have-nots has been widening, both in rich countries and poor.

As a powerful minority increasingly influences public elections and subverts democratic process, the rights of the poor have been increasingly undermined. The World Bank and IMF – who are clearly under the thumb of the world’s ruling class – have pressured poor countries to privatize health services and slash public spending for those in greatest need. Adding fuel to the fire of unsustainable development policies and global warming, the misguided escalation of biofuel production is swallowing up more and more farmland and basic crops to feed cars, not people. As food prices soar and the global situation heats up, the poor are the first to be burned. For those on the bottom of the stack, adequate food and health care are even further out of reach.

(For further discussion on the sociopolitical determinants of health see Questioning the Solution: The Politics of Primary Health Care and Child Survival by David Werner and David Sanders —)

In the past, poor people have turned to traditional healers – herbalists, bonesetters, midwives, tooth-pullers, shamans, etc. – for the majority of their ailments. But as institutionalized Western medicine has spread around the globe, the healing arts have increasing become the jealously guarded domain of a coterie of medical professionals. Laws have been passed prohibiting the practice of medicine –including dentistry, midwifery, and most other healing skills – without a license. And to get a license requires years of largely ritualistic classroom training.

The rationale for current licensing practices is to guarantee a high quality of service, and to protect the interests of the sick and suffering. But the end result in fact is to create an elite monopoly that gives a privileged class of practitioners control of the access to needed health resources. Often this powerful elite puts its own financial gain before the health needs of the poor. In this context, a medical degree becomes a license to exploit. The exploitive nature of modern medical care is especially evident with the growing number of medical professionals in private practice.

Some doctors – many in fact – reject the get-rich temptation and elect to work for the common good. Yet even in health centers that are entrusted to provide free services to the indigent, some doctors charge people under the table, or sell poor people costly medicines where much cheaper medicines – or drug-free self-help remedies – would work as well or better. The result of such elevated pricing is that people often can’t afford the full medical treatment. For certain serious diseases this can be disastrous as it can lead not only to treatment failure but to the emergence of resistant strains of pathogenic microbes.

A related problem is that often licensed doctors, dentists, and other health professionals are unwilling to go to – and even less, reside in – the impoverished rural areas or neighborhoods where the needs are greatest. At a time when Mexico City had 5000 unemployed doctors who refused to leave the capital, more that half of the nation’s municipalities had no licensed doctors at all.

Yet while there is a great scarcity of doctors in the most marginalized areas, many countries have introduced laws that prohibit the practice of medicine or dentistry without a license.

The result is, of course, a growth of illegal or clandestine practice. Some of this unauthorized practice is dangerous or exploitative. But a remarkable number of these non-licensed healers have sufficient knowledge and healing skills to make a substantial contribution to the health of their communities, and they provide their services to people in need in a humane manner. In countries where modestly trained health workers, dental technicians, and midwives have been accepted and allowed to practice, often they have made a big contribution to health. And where such lay workers have been integrated into the health system and been given short courses, guidance, and the back-up services they request, often impressive gains in maternal and child health have been realized.

In the 1950s into the 70s the failure of the high cost, professional, hospital-based Western medical model to meet the health needs of poor majority in the “Third World,” became vexingly apparent. A variety of pioneering alternatives were tried, a few at the national level. The most renowned of these was the barefoot doctor initiative in China, which – as part of a social revolution entailing more equal sharing of land and wealth – led to phenomenal improvements in health.

In other poor countries, where social inequities were deeply entrenched, the unmet needs of the impoverished majority led to many non-government initiatives in “community based health care.” Such grassroots initiatives arose in isolated and poor communities, often with strong popular participation. Typically they involved a comprehensive approach in which people collectively analyzed and took organized action to address the underlying socioeconomic determinants of health. In some countries this grassroots community-based health movement played a leading role in the organized struggle for social justice and democratic government. In some cases – as in the Philippines and Nicaragua – community based health programs played an important role in the ousting of tyrannous regimes.

Impressed by the accomplishments of this people-empowering, rights-based approach to health care, in 1978 the World Health Organization and UNICEF organized a meeting of the world’s governments in which they launched the goal of “Health for All by the Year 2000.” To work toward the achievement of this goal, they proposed a comprehensive operational plan called Primary Health Care (PHC), which was endorsed by virtually all the world’s nations.

Primary Health Care, as outlined in the groundbreaking Alma Ata Declaration, called for different levels of health workers, with a strong emphasis on local, community-based workers who were selected by, and felt responsible to, the people they served. Essential to the success of these frontline workers would be the backup of the professional health system, complete with easily accessible referral to secondary and tertiary care. In sum, the first line of services would be provided by a large cadre of community-level health workers.

It was recognized by those who designed the concept of Primary Health Care that there would never be enough doctors to go around (except in places like Cuba). And even if there were enough doctors, with the high cost of their training and employment, the exclusive use of fully trained doctors would never be an economically feasible way of meeting everybody’s needs. The architects of Alma Ata recognized that the vast majority of the day-to-day health problems – including the commonest killers of children, such as diarrhea and pneumonia – could be dealt with faster, cheaper, and often more effectively by local health workers and well-informed people in the children’s own homes. Health workers who are from the villages or neighborhoods of those being treated – especially if they come from humble backgrounds themselves – tend to have a better understanding of the local customs and needs. Often they are more ready to share their knowledge and skills with other first-line health providers in the community, especially mothers.

Also, because the local health workers share in common the hardships of the other villagers, they often are more concerned with the underlying social and economic determinants of health. They are therefore more likely to help mobilize the disadvantaged or exploited to stand up for their rights and help build healthier, more inclusive social structures. They often become agents of change, mobilizing their community in the perennial struggle to build a fairer, healthier society – from the bottom up.

(See “The Village Health Worker, Lackey or Liberator.” David Werner, May 1997 )

Indeed, it was this comprehensive approach to meeting health needs, with its emphasis on popular participation and building fairer, more egalitarian socioeconomic structures, that gave the Alma Ata Declaration its revolutionary potential. By implication, it proposed taking the control of health-related concerns out the hands of the medical elite and putting “health in the hands of the people.” The doctors were to be on tap – not on top.

For obvious reasons, the revolutionary, equity-oriented model of Primary Health Care as proposed at Alma Ata soon met with resistance from the powers-that-be, including much of the mainstream medical establishment. Most governments, rather than striving toward “Comprehensive Primary Health Care” that would put more control over the determinants of health in the hands of the people, opted for a politically conservative option known as “Selective Primary Health Care,” first promoted by the Johns Hopkins School of International Public Health. This politically conservative PHC model, stripped of egalitarian politics, was designed to improve the health statistics of high-risk groups (mainly impoverished children) through the top-down implementation of a few, carefully selected, low-cost technological fixes, without doing anything to upset the entrenched inequities of the status quo.

The chosen interventions of Selective PHC included primarily Immunization, and Oral Rehydration Therapy (ORT). ORT was based on wide distribution of commercially produced packets of Oral Rehydration Salts (ORS) to be given to children with diarrhea. While the health benefits of Immunization and ORT are obviously real, the focus on these interventions – to the exclusion of structural changes to make sure that all children get enough food – is in some ways counterproductive.

(See [[ http://healthwrights.org/articles/who_killed.htm| “Who killed Primary Health Care? How the ideal of ‘Health for All’ was turned into the reality of worsening the health of the world’s poor.” David Werner. New Internationalist, 1995.)

Needless to say, Health for All was not achieved by the year 2000. On the contrary, the gap in levels of both wealth and health continued to widen, both within countries and between them, as it continues to do to this day. Twelve million children continue to die every year of preventable diseases. According to UNICEF and WHO, over 60% of these child deaths are related to malnutrition.

Some people say that Primary Health Care failed. But in truth, it was never really tried – at least not in its comprehensive, revolutionary form. It was disemboweled of its change-producing potential by the global power structure and medical establishment before it ever got off the ground.

Today the needs for a more comprehensive and socially inclusive approach to Primary Health Care are more urgent than ever. As medical costs continue to escalate, as global climate change and environmental mismanagement push costs of fuel and food higher and higher, and as wealth further concentrates in the hands of a myopic ruling class, growing numbers of people are deprived the most basic health services. Millions never see a doctor in their lives. Billions can’t begin to afford the health services that are available.

More and more countries are enforcing laws that prohibit non-professionals from providing crucially needed services – especially if they give prescription drugs or use injections. Those who practice without a license are sometimes harshly punished. As result, a vast number of the world’s neediest people go without basic services. A lot of relatively minor ailments, for lack of relatively simple but timely attention, end up causing an unconscionable amount of suffering, disability, economic ruin, and death.

On a recent visit to Borneo, Indonesia, I witnessed the plethora of ill health and suffering that has resulted from the lack of adequate professional health services combined with the outlawing of lay healers. I had been invited as a consultant to a non-government program called Health in Harmony, in West Kalimantan. This pioneering program is taking a holistic approach, combining community health care with protection of the endangered rainforest. So that poor people don’t go without health care for lack of funds, families are invited to pay for medical services with work rather than cash. They are developing a program in which much of this work-payment will be in eco-friendly work: activities like planting trees and protecting the forests from illegal logging. Health in Harmony has a team of about 15 medical and environmental professionals, including 3 doctors, several nurses, and a dentist. The services are of high quality, and although the program is only a few months old, already people with serious health problems pour in from farther and farther away.

Because of the inadequacy of other health services locally, there is a tremendous backlog of people with advanced chronic conditions that have been either untreated or inadequately treated. The HIH doctors estimate that 70% of the population has active tuberculosis. Untreated high blood pressure and cardiac disease lead to a high incidence of strokes and heart attacks. Diabetes is rampant and often disabling. The HIH dentist reports that the entire population, including young children, has serious tooth decay – partly because babies are weaned from the breast directly onto junk food.

No matter how hard this dedicated HIH team works, providing services to people who have previously been too poor or isolated to get the care they need, they can only put a small dent in the colossal backlog of needs.

The needs seem overwhelming, especially in view of the high unemployment, rock-bottom wages, stifling bureaucracy, and inadequate public services. Yet a great many of the medical needs could be met by modestly trained community health workers and dental technicians. To a large extent, high blood pressure and diabetes could be diagnosed and controlled by lay workers, trained and backed up by the HIH staff. The huge backlog of rotten teeth could be pulled by a modestly trained cadre of dental workers – members of the community selected for their caring attitude and steady hands. Early childhood pneumonia could be identified and treated with standard appropriate antibiotics.

There is nothing magical about such basic services. No long ritualistic period of academic training is required – just a few simple clearly designed instructions, in a language and with pictures everyone understands, combined with hands-on practice under the tutelage of a capable role model.

There is much evidence that such a simplified, common sense approach can yield good results, especially when candidates for community health and dental work are selected by the community for their human qualities, rather than for their wealth or political clout. There are examples from around the world where this has been achieved.

In Mexico’s Sierra Madre, where I worked for 30 years with a villager-run health program (Project Piaxtla), the promotores de salud (health promoters) had an average of three years of primary school education. Their initial training consisted of 6 weeks of hands-on practice and apprenticeship (mostly learning how to use the handbook Where There Is No Doctor). Yet within a decade the village health team – with no health professionals present except for occasional teaching visits by volunteers – managed to reduce the child mortality rate by 80 percent (from 340 to 65 under-5 deaths per thousand).

Similarly, in a very impoverished tribal area of Arunachal Pradesh, India, illiterate mothers identified the two commonest killers of their children: pneumonia and diarrhea. Using simple techniques adapted to their culture, they were taught to recognize basic signs of early pneumonia and treat it with a low-cost antibiotic, and to prepare oral rehydration drinks for children with diarrhea. In one year they succeeded in lowering child mortality by more than half.

The potential of dedicated, modestly trained health workers is enormous. If the health team of the Health in Harmony program in Borneo were able to spend more of their time training village health workers in the prevention and treatment of the most common afflictions, and provide supportive backup for those workers who felt they needed more expert assistance, the net result of the program would be to reach far more people. Through this multiplying effect, they could achieve a far greater impact on the health of the community.

The same is true for Health in Harmony’s dental program. If the dentist were to train a group of nimble-fingered and good-hearted villagers in the essentials of tooth extraction, she could multiply the number of people she is able to reach. In time she could teach her apprentices to master the basic techniques of drilling and filling. At first her trainees could work under her direct observation. When they acquired sufficient skill and experience they go out into the community and begin to work on their own, with clear guidelines about referring the more problematic tasks back to the dentist.

In our village health program in Mexico, with help from visiting dentists, we were able to train village health workers to competently extract teeth within a few weeks. This included the ability to correctly and safely use an injectable local anesthetic. Those who were interested in learning more, with an additional two months of apprenticeship, learned to successfully drill out and fill most kinds of cavities. Dental workers trained in this manner have now been working in the area of the village health program for more than 20 years. Some have also become skilled at making dentures. They all continue to provide an invaluable, good quality, low-cost service to poor communities where licensed dentists fear to tread.

“But surely such modestly trained health and dental workers are more likely to make mistakes!” you may think. True, everyone makes mistakes. But mistakes often have more to do with attitude and respect than length of training. If the workers are selected for their compassion and eagerness to serve, and are taught to work within their limitations, the risks are reduced. Sometime the quality of the work modestly trained technicians is as good or better than that of highly trained, licensed professionals.

This was demonstrated in the early 1980s by a study conducted by the Forsyth Center in Boston. A group of high school graduates, mostly girls, were trained for six months in drilling and filling cavities. They started on teeth that had been pulled, and then went on to teeth in people’s mouths. On completing their relatively brief training, the quality of their work was compared with that of practicing dentists, as judged with patients coming our of randomly selected dentists offices. The study found that the professional dentists made 7 times as many serious errors as did the briefly trained girls. However, the study was never completely finished because the Dental Association got a court order to cut it off in midstream – on the grounds that the girls were practicing without a license!

Experience has shown that a very large proportion – perhaps 90% – of the health and dental work most needed in communities – and most frequently performed by doctors and dentists – could be capably performed by caring persons with far less formal training, at far more reasonable costs. When local health workers are selected and trained to serve their own communities and extended families, often they have more empathy, and are less likely to exploit those they attend, or treat them as inferiors.

It is important that the humanitarian health professionals who chose to work in marginalized communities be able to multiply their effectiveness as much as possible. To improve the health of people where needs are great and services are few, such professionals need to return to the original meaning of the word “doctor,” which is teacher. They need to devote a major part of the time to training and backing up a much larger workforce of community health promoters who can provide early, accessible care, when and where it is most needed.

The Health in Harmony team in the Borneo rainforests would like to do just that. But unfortunately, they feel their hands are tied. For community health and dental workers to be fully effective, they need to be able to provide basic curative care when the need arises. To gain the confidence and cooperation of the people, simply to provide health education and preventive measures is not enough. At a minimum, the health worker needs to know how to prescribe and use at least a few basic antibiotics and other essential drugs. The dental technician needs to know how to capably and safely use injectable local anesthesia. But for this, they need to be permitted by the health authorities to do so.

It is understandable the health authorities should be reluctant to grant such permission. The over use and misuse of certain prescription drugs, especially antibiotics, is a huge problem that has led to disastrous, far-reaching consequences.

But who is a fault? Flagrant misuse and overuse of medications is part of the standard practice of the majority of medical professionals. This is true in the highly regulated industrialized countries, and even more so in poor countries where medical malpractice is often extensive and where people have little or no recourse.

One of the biggest challenges in training community health workers is to prepare them to weigh risks against benefits, and use a very limited number of essential medicines, correctly, and only when necessary. It is their responsibility, within the limited range of their training and ability, not only to perform as well as the average doctor, but better.

Because the unmet health needs of so many people are so great, and because the services of licensed doctors and dentists do not reach large sectors of the population, there is an urgent need for modestly trained medical and dental workers who identify with the underserved. It is important that health programs serving marginalized communities, like Health in Harmony in Borneo, do what they can to train local health workers and dental technicians to be the frontline health promoters in their communities.

It is equally important that such programs advocate for more flexible legislation. Health ministries, rather than prohibiting the use essential drugs and injectable dental anesthesia, must be convinced to promote the cautious, well-informed use of such medications, both by licensed MDs and other highly educated professionals and by more modestly trained community workers.

To this end, different NGOs and community organizations need to pull together – if possible with the cooperation of WHO, UNICEF and human rights organizations – to encourage governments to acknowledge and support community health and dental workers. Laws need to be flexible enough to allow such heath workers, with an adequate support system, to judiciously use critically needed, potentially lifesaving and pain-preventing medicines.