health - ldb.orgldb.org/iphw/pha2000.pdf · making this dream come true. we believe that health is...

1Health in the Era of Globalisation

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PHA Secretariat, Gonoshasthaya Kendra Savaremail: [email protected]; website: www.pha2000.org

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People�sHealth

Assembly

Healthin the

GlobalisationEra of

from victims to protagonistsA discussion paperprepared by the

PHA drafting group

2 People’s Health Assembly

CONTENTSCONTENTSCONTENTSCONTENTSCONTENTS

THE PEOPLE’S HEALTH ASSEMBLYTHE PEOPLE’S HEALTH ASSEMBLYTHE PEOPLE’S HEALTH ASSEMBLYTHE PEOPLE’S HEALTH ASSEMBLYTHE PEOPLE’S HEALTH ASSEMBLY 3

Who are we?Why the need for a People’s Health Assembly (PHA)?How we will achieve our objectivesHow you can participate in the People’s Health AssemblyCurrent structure of the PHA

THE PHA VIEW ON WORLD HEALTHTHE PHA VIEW ON WORLD HEALTHTHE PHA VIEW ON WORLD HEALTHTHE PHA VIEW ON WORLD HEALTHTHE PHA VIEW ON WORLD HEALTH 6Introduction 6The structure of this paper 6The current health crisis 7What do we mean by ‘health’? 9Determinants of the health crisis* 9

Causal factors affecting health

1. The political economy of health2. The social environment3. The physical environment4. The health sector

The way forward: Challenging the inequitable and unhealthy 16global model of development

1. Movements for change.2. Levels and avenues for change3. Types of action for change

Examples of specific actions for a healthier world: 23An Emerging PHA Action Plan

1. The political economy.2. The social environment3. The physical environment4. The health sector

* * * * * More complete papers on each of the four main determinants ofhealth and well-being covered in part C of this framework are available as supplementary background material. A number of ‘issue papers’ onvarious related topics are also being made available.

For additional information and background discussion materials contact:PHA Secretariat, Gonoshasthaya Kendra Savaremail: [email protected]

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WHO ARE WE?

The People’s Health Assembly (PHA) is aninternational, multisectoral initiative aimed atbringing together individuals, groups, organi-

sations, networks and movements long involved inthe struggle for health. The idea started 15 years agowhen peoples’ organisation realised that the WorldHealth Assembly of the World Health Organisation(WHO) was unable to hear the people’s voice and anew forum was required. It is just now that we aremaking this dream come true.

We believe that health is a fundamental humanright that cannot be fulfilled without commitmentto equity and social justice. Our strength lies innumbers, and in the sharing of creative, alternativeideas for solutions. By creating a world-wide, interand multi-sectoral collective of caring people andgroups that includes people from all classes, castes,creeds, ages, gender, disabilities, ethnic origins andnations, we strive to make our voices heard.

WHY THE NEEDfor a

Individuals and groups behind this initiativebelieve that, through the active participation ofwell-informed and concerned people, the fight

for a healthier, more just and sustainable world ispossible.

The prime objective of the PHA is to give a ̀ voice to`voice to`voice to`voice to`voice tothe peoplethe peoplethe peoplethe peoplethe people and make their voices heardand make their voices heardand make their voices heardand make their voices heardand make their voices heard” in deci-

PHAPeople�sHealth Assembly

Please send your comments and feedback to Nadine Gasman. Fuente del Emperador 28Tecamachalco C.P.53950. México

FAX: 525-2512518 or [email protected]

The PHA process has three phases: pre-Assembly activities; a major international Assemblyevent and post-Assembly activities. Large

numbers of people are already involved in the pre-Assembly activities and we expect many

more to getinvolved before December 2000. In particu-

lar, we hope that people will get actively involved inPHA activities in their home countries.

Pre-Assembly activitiesThese include local, regional and national discus-sions focusing on the problems affecting differentpeople and communities, and their struggles forchange. People’s experiences and collective effortsto cope with, reform, or transform their currentunhealthy situation will be shared through thecollection of stories and case studies,. These experi-ences have fed into this background paper and theassociated discussion papers. They will alsoprovide a major input to the formulation of a draftPeople’s Charter for Health (PCH). These experiences

PEOPLE�S HEALTH

sions affecting their health and well-being. It isthrough collective action that we will begin tochange the unfair and unsustainable top-downprocess of globalisation – and its current negativeimpact on our overall health and well-being.

The PHA provides an opportunity to presentpeople’s perspectives on health. We invite you toadd to these ideas by putting forward your ownvisions and dreams for a healthier society.

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HOW WE WILL ACHIEVEOUR OBJECTIVES

ASSEMBLY?


will be presented and shared during the Assemblyevent.

The Assembly eventScheduled for 4–8 December 2000, the Assemblywill be held at Gonoshasthaya Kendra (GK), Savar,37 km North of Dhaka, Bangladesh. We expectaround 600 participants, representing people andtheir experiences from across the globe.

The Assembly will be followed by a three-dayFollow-up Forum, where participants will havefurther opportunities to share experiences, networkand meet with local community groups in Bangla-desh. Through these interactions, the PHA willgather additional in-depth content.

Post-Assembly activitiesThe focus will be on disseminating, promoting andseeking wider endorsement and implementation ofthe People’s Charter for Health and other materialsgenerated by the Assembly. Advocacy and lobby-ing activities at the local, national and internationallevels will be planned, and mechanisms for furthernetworking among participating individuals andorganisations will be coordinated. The post-assem-bly activities will form a long-term process oforganisation and action for change.

CURRENTSTRUCTURE OF

THE PHA

The PHA is currently coordinated byrepresenta-tives of eight convening international organisations (the Coordinating Group)

which represent groups and networks activelyinvolved in promoting health and people’s empow-erment around the world. Regional Coordinatorshave been appointed to facilitate the work of thePHA, communicate and foster participation in allregions. National Preparatory Committees are

working in some countries.

There is a Secretariat in Savar, a Fundraising groupand an drafting group. There is continuous com-munication between all these groups.

HOW YOU CAN PARTICIPATE

in the PHA

We invite all people and organisations thatsubscribe to the concept of health as ahuman right and comprehensive Primary

Health Care to participate in the PHA process.

There are several ways to participate:

P We invite you to share stories and case studiesstories and case studiesstories and case studiesstories and case studiesstories and case studieswhere you describe your health problems and/or locally generated solutions with the PHA.

P You can organise meetingsorganise meetingsorganise meetingsorganise meetingsorganise meetings in your communityor organisation (please contact the regional ornational coordinator for support and registra-tion).

P During the pre-assembly process you canparticipate in planned PHAparticipate in planned PHAparticipate in planned PHAparticipate in planned PHAparticipate in planned PHA meetingsmeetingsmeetingsmeetingsmeetings at local,regional or national level (please contact theregional or national coordinator for a list ofupcoming meetings).

P You can participate in the development of thePHA analytical background documentsanalytical background documentsanalytical background documentsanalytical background documentsanalytical background documents (suchas this paper) and the People’s Charter forPeople’s Charter forPeople’s Charter forPeople’s Charter forPeople’s Charter forHealthHealthHealthHealthHealth.

P Some will be able to participate in the PHAPHAPHAPHAPHAassemblyassemblyassemblyassemblyassembly in Savar, Bangladesh, 4-8 December2000. The number of participants will beapproximately 600. Our aim is to ensuregeographical spread and gender balance.Preference will be given to people from thegrassroots level. To achieve this balance aparticipatory selection process coordinated at

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The draft background documents may be obtained from thePHA Secretariat, Gonoshasthaya Kendra Savar

E-mail: [email protected] or downloaded from www.pha2000.org

the regional level has been developed. (Forfurther information please contact your re-gional or national coordinator).

Despite the relatively small number who will beable to attend the December event, we hope peoplewill involve themselves in local, regional or na-tional activities, contribute to the PHA documentsand/or interact through our website(www.pha2000.org).

Application forms for the December meeting maybe obtained from the PHA Secretariat or the regionalcoordinators (see addresses below).

The preparation of the background documents,background documents,background documents,background documents,background documents,the People’s Charter for Health the People’s Charter for Health the People’s Charter for Health the People’s Charter for Health the People’s Charter for Health and the Action the Action the Action the Action the ActionPlanPlanPlanPlanPlan involves two key components:

P the analysis of the causes of global and localproblems affecting people’s health and well-being, and

P a review of actions and alternatives people haveadopted to cope with or overcome these prob-lems.

We believe that, we will collectively produce solid,hard-hitting background documents that willprovide some useful evidence to grass-root organi-sations in our fight to improve people’s health andaddress the global health crisis.

The PHA drafting group has begun by drafting anoverview paper (which you are reading right now)

and five ̀ sectoral’ papers on the topics: the politicaleconomy of health, the social environment andhealth, the physical environment and health, thehealth sector and a paper describing strategies andmethods to improve communication and learning.These papers can be used as discussion materials atyour local, regional and national meetings.

We are also in the process of finalising a first draftof the People’s Charter for Health as a basis fordiscussion. This Charter has as its starting point theAlma Ata declaration, the Patient Bill of Rights,Child Rights, the Convention on the Elimination ofAll Forms of Discrimination Against Women(CEDAW) and other relevant people orienteddeclarations and Charters. We hope you will sendus your comments and inputs in time for theAssembly event where the PCH will be endorsed.

We welcome feedback from concerned individualsand groups on all the documents prepared for thePHA, including this paper. Further, we wouldwelcome your submissions of concrete action pointsthat you would wish to see included in an overallaction plan.

We urge you to help us identify suitable stories,case studies, papers and audio-visual materials thatmay illustrate some of the realities experienced byyou and illustrate the points made in these papers(or points not yet made!). Such material is beinggathered from all over the world and will serve as abasis for deliberations at the Assembly.

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THE STRUCTURE OF THIS PAPERTHE STRUCTURE OF THIS PAPERTHE STRUCTURE OF THIS PAPERTHE STRUCTURE OF THIS PAPERTHE STRUCTURE OF THIS PAPERThis draft paper aims to provide an overview of the current health situation, its major determinantsand a number of suggested solutions. It also serves as an introduction to the five background papersand we hope it will be a source of inspiration when you consider the People’s Charter for Health, andproposals for the Action Plan.

The analytical part of the paper begins with a discussion of the Current health situation in the worldand a definition of What we may mean by ̀ health’. . . . . It is followed by a discussion of the major Causesand determinants of the current health crisis. We have divided this into four broad sections: the politicaleconomy, the social environment, the physical environment, and the health sector. (These four areasare explored in more detail in separate background papers.)

Following the analysis, there is a section on Strategies and actions for change. This analyses andreflects on what is needed to challenge the current unfair and unhealthy situation. We conclude byoffering some Concrete examples and suggestions for action at different levels—from local to global.

Throughout the document, you may find questions that can be used to startThroughout the document, you may find questions that can be used to startThroughout the document, you may find questions that can be used to startThroughout the document, you may find questions that can be used to startThroughout the document, you may find questions that can be used to startdiscussions and give your feedback to the PHA process.discussions and give your feedback to the PHA process.discussions and give your feedback to the PHA process.discussions and give your feedback to the PHA process.discussions and give your feedback to the PHA process.

We are very interested in your feedback and suggestions on this draft paper.We are very interested in your feedback and suggestions on this draft paper.We are very interested in your feedback and suggestions on this draft paper.We are very interested in your feedback and suggestions on this draft paper.We are very interested in your feedback and suggestions on this draft paper.

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INTRODUCTION

The need for the ̀ democratisation of global decisions’ is critical as we move into the new century. Global policies affecting our present and future well-being are made by few power-fulinstitutions like the World Trade Organisation (WTO), the World Bank (WB) and the Interna-

tional Monetary Fund (IMF), together with the transnational corporations (TNC) and the Northernand Southern governments supporting globalisation. These ̀ power cliques’ of the global economyare pushing globalisation at the cost of people’s lives and the deterioration of the environment.

The resulting gap between rich and poor, both between and within countries, has led to deepeningpoverty, falling real wages, unemployment, deterioration of health, increased disease and disability,despair and a global epidemic of crime, violence, disease, disability and despair. While some peoplelead lives of over-consumption that damage their health and endanger the planet’s ecosystems,millions suffer from hunger and deprivation. This unfair global socio-economic system is as unsus-tainable as it is inequitable. The ideology of ‘growth at any cost’ is leading, at an accelerated pace, tothe disintegration of our social fabric and the destruction of the environment.

Despite this grim scenario, there is a myriad of positive examples of individuals and groups from allover the world, coming together to fight injustices and seek alternative solutions. While these move-ments are still in their infancy, they are beginning to threaten established power structures. In all thediversity of the causes they represent—health, agriculture, education, environment, human rights,disarmament, gender or ethnic equality—these popular movements are forming networks andincreasingly discovering the common roots of their sectoral problems recognising the inter linkagesand alternatives of action they can share and support.

Health, which in its fullest sense encompasses the physical, mental, social, economic, environmental,and spiritual well-being of people, is of concern to everyone and has the potential to unite a broadbase of people’s movements. The potential has never been greater and the need has never been moreurgent.

The time to take united positive action is now!The time to take united positive action is now!The time to take united positive action is now!The time to take united positive action is now!The time to take united positive action is now!


An analysis of the health situation and itsdeterminants is a story of inequality andunequal distribution. Although the last 50

years have witnessed improvements in life expect-ancy, declining mortality rates (especially infantmortality), and lower fertility rates in most coun-tries, these numbers tend to hide the real disparitiesbetween and within countries, between socialclasses and between men and women.

In 1999, 20 million people died before reaching theage of 50, while the mean world life expectancy was66 years. Taking this relatively modest age as aminimum of what should be morally acceptable, wecan conclude that 40% of all deaths in that yearcould be considered premature and preventable. 1

While mortality rates in children under five yearsold are less than 10 per 1 000 live births in mostcountries in the North, most countries in the Southhave rates of between 50 and 100, and over 10countries in Africa have figures of over 200. Fur-thermore, in a number of sub-Saharan Africancountries infant mortality rates actually startedincreasing in the 1980s due to economic recession,structural adjustment, drought, wars, civil unrestand HIV/AIDS. Since the beginning of the epidemicthere are more than 13 million orphans due toAIDS2 .

Even so-called developed countries have seenworsening of health indicators among certainsectors such as decreased life expectancy amongmales in rural areas in Australia brought about bylong term unemployment caused by globalisationand consequence of depression and suicide. Otherexamples are found in the higher morbidity andmortality rates of Afro-Americans in the UnitedStates.

In short, despite some gains, we have not madesubstantive improvements in the main underlyingdeterminants of health. Levels of poverty remainunacceptably high, natural resources have beendrastically depleted and there has been furtherdegradation of the global environment, in thelonger-term threatening everybody’s health. Al-though the world produces more than enough foodto feed its entire population adequately and medi-cal technology has made many advances, thesebenefits are unevenly distributed. Wealth andknowledge are increasingly concentrated in FirstWorld countries and the gap between the have andthe have-nots continues to widen in all countries.This is a central issue of human rights and social

justice.

Each year, over 12 million children continue to diefrom preventable diseases. An underlying cause inmore than half of these deaths is undernutrition orhunger. ‘Diseases of poverty’, mostly infections andparasitic diseases, as well as women’s reproductivehealth problems, and chronic diseases or ‘diseasesof modernity’, are on the increase. Cancer, hyper-tension, diabetes, obesity, accidents and depressionhave become serious world public health problems.Third world countries are faced with the doubleburden of disease where infectious and chronicdiseases are on the rise. This requires investmentand adjustment of the health services which areimpossible given the economic and political con-strains they face.

There has also been a resurgence of ‘old diseases’such as tuberculosis, malaria, and vaccine-prevent-able diseases. This is as a direct result of increasingpoverty, deteriorating living conditions and inad-equate health services. New diseases such as HIV/AIDS have appeared and are spreading mostrapidly where social and gender inequalities are thegreatest. Increasing crime and violence add to thisgrowing health crisis. The same is true for substanceabuse, increasing violence, suicide and other ‘dis-eases of despair.’ Far from reaching the interna-tional goal of ‘Health for All by the Year 2000,’ thehealth of humankind is sadly compromised.

Equality between the genders has been on thepolitical agenda of many countries and organisa-tions, and progress is apparent in some countries.However, discrimination against women continuesto be a world-wide problem seriously compromis-ing their health. In some countries, discrimination

THE CURRENTHEALTH CRISIS


starts before birth and remains part of women’slives until death. More than half a million womendie every year due to conditions related to mother-hood. The overwhelming majority of these prevent-able deaths occur in the developing world, espe-cially in Africa.

The increasing number of elderly in all societiesrequires that conditions be created now for healthyageing. Attitudinal, physical and economic barriersto the inclusion of disabled people have still to beremoved to ensure their full participation in eachsociety.

AIDS is set to alter history in Africa—and theworld—to a degree not experienced by humanitysince the Black Death.

Poverty and the lack of general medical care causedby rampant inflation and joblessness are majorcontributors to the AIDS epidemic in Africa – alongwith the social and cultural particularities of thatcontinent. In Zimbabwe for example, nearly 40% ofthe women who present themselves for HIV coun-selling and testing turn out positive. Studies havealso found that the HIV infection rate among 15–20year old girls is five times that of boys of the sameage. AIDS is really a development and povertyissue and should be treated as such.

Large numbers of people of all age groups arefinding it harder and harder to cope with suchcharacteristics of modern life as increased unem-ployment, solitude, crime, domestic violence,environmental degradation, mental health prob-lems, and the lack of physical, emotional andeconomic support systems.

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Important disparities also exists in the provision ofhealth services. It is paradoxical but in the world’spoorest countries, most people, particularly thepoor have to pay for health care from their ownpockets at the very time they are sick and most inthe need of it. The World Health Report 2000 findsthat “many countries are falling far short of theirpotential, and most are making inadequate effortsin terms of responsiveness and fairness of financialcontribution”3 .

In the face of these alarming developments, moreand more people are finding the need to organisethemselves and find solutions to their underlyingproblems.

A central thrust of the PHA process is to foster andmultiply such efforts through which people acquirethe power to make the necessary changes.

What can you add to this overview of thecurrent health situation?

Do you have experiences and/or knowledge thatsupport or challenges these points?

What important aspects have, in your view,been left out so far?


The paper is based on the objectives and aspirations of the People’s Health Assem-bly, whichstrives to ensure that all people, regardless of

age, gender, race, disability, nationality, social class,caste, place of residence, and sexual or religiouspreferences, have the opportunity to fulfil theirpotential.

We accept the World Health Organisation’s defini-tion of health as a complete state of physical, mentaland social well-being and not merely the absence ofdisease or infirmity. This holistic health conceptviews health as a state of equilibrium betweenhuman’s external and internal environment.

However, in the PHA we take the issue of healthfurther and see health and sustainable well-being forALL as the central objective of social development.We see health as a fundamental human and socialright to strive for.

To ensure health, peoples’ basic needs for food,water, sanitation, housing, health services, educa-tion, employment and security must be met. Toenjoy more than just physical health, people needself-esteem; they need a sense of purpose, meaningand belonging. Healthy societies require a balancebetween individual freedom and responsibility.Love, culture of compassion, care and respect forlife and spirituality are as important to the well-being of individuals, communities and nations as isthe economy.

Do you agree with this view onwhat health consists of?

Do you have a different definition of health?

The PHAThe PHAThe PHAThe PHAThe PHA is founded on the belief that

together we can build a better world, and thatorganised grassroots action can bring about positivesocial change. Action for change needs to begrounded on a sound assessment—or ‘situationalanalysis’—of the current reality. Such a collectiveanalysis needs to explore the immediate, underly-ing and basic causes of ill health and how theserelate to the interconnected crises of our times.

This paper starts by looking at the problems thatface humanity and compromise its health. Somepointers follow this to ways forward. It discussesmethods of awareness-raising, and explores arange of possibilities for positive, constructiveaction. It includes examples of effective actionpeople have already taken to change their situation.

Causal factors affecting healthCausal factors affecting healthCausal factors affecting healthCausal factors affecting healthCausal factors affecting healthDifferent factors, acting at different levels, determinethe health of individuals, families, communitiesand nations.

The most immediate factors immediate factors immediate factors immediate factors immediate factors that affect healthrelate to starvation, lack of access to water, inad-equate food intake, exposure to infectious diseases,intoxication from an unhealthy environment,smoking, inadequate treatment by health services,accidents and violence. The basic factorsbasic factorsbasic factorsbasic factorsbasic factors, in turn,relate to lack of food security, lack of safe water,unsafe working conditions and the way the healthservices are organised in terms of their accessibility,adequacy and quality. The underlying causes underlying causes underlying causes underlying causes underlying causes arethose major cross-cutting issues such as the shape ofthe economy, environment, agriculture, employ-ment, fairness of wages, human rights, genderissues, and education.

These factors are interrelatedinterrelatedinterrelatedinterrelatedinterrelated andreflect the economic and socio-politicalconditions of a country—and increas-ingly, our globalised world. In ordertruly to achieve health for all, far-reaching transformation of society atthe underlying level is needed. Suchtransformation must be directedtowards a more equitable distributionof power and resources, participatorydemocracy and good governance withimproved accountability and transpar-ency.Health cuts across all aspects of soci-

of theHEALTH CRISISDETERMINANTSWE MEAN BY

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ety. Any division into clusters or thematic areas istherefore arbitrary. For purposes of our analysis wehave chosen to present them in the following fourareas:

1. The political economy2. The social environment3. The physical and natural environment4. The health sector

1. The Political Economy of healthThe most significant determinants of health in theworld today are economic and political factors thathave colonial roots. Who has control over resourcesand decision-making, and who has the power overwhom, determines the way countries and the worldare organised and ruled. This impacts on the healthstatus of people and the way health services areorganised. Most of the underlying and basic causes ofill health can be found here and the solutions beingoffered benefit much more the planners, loan givers-usually international financial institutions and theassociated governments- than the recipients. Theirneeds are usually not met and end up loaded withheavy debt servicing, which results in furtherexpenditure cuts in essential social services. From ahealth point of view, the current trend towardseconomic globalisation, the lack of equity anddistributive justice aggravates the growing healthcrisis and widens the growing inequality gap.

Statistics show the existence of overwhelminginequalities in the world today:

P Total GNP per capita (global production perperson) has more than doubled in the last 50years. More than enough food and goods areproduced to meet all people’s basic needs. Yetone in every four children is malnourished.

P At the end of the 1990s, a fifth of the worldpopulation living in ‘rich’ countries com-manded 86% of the world’s GNP while thepoorer fifth commanded only 1%.4 As a result,poor people are denied access to basic resourceslike food, clean water, shelter, a safe and cleanenvironment, and are increasingly exposed toviolence.

P Wealth and power have become more and moreconcentrated in the hands of a small powerfulminority. A handful of transnational corpora-tions (TNCs) currently control 33% of theworld’s productive assets, while they employonly 5% of the global workforce5 . Annualturnover of many TNCs exceeds the annualbudgets of several large developing countries.

P Today the 450 richest persons in the world havean annual income greater than that of thepoorer half of humanity. While the chief execu-tive officers of giant corporations have incomesin the millions of dollars, one fourth of theworld’s people struggle to survive on less thanUSD 1 dollar per day. Many have to do so byselling their last resource, namely themselves,that is their blood, organs and engage in sexualslavery.

P Financial institutions such as the World Bankand the International Monetary Fund have beenmajor influences in determining the currentmodel of development. They have universallyprescribed structural adjustment programmes(SAPs), which have cut employment andinvestment in the social sectors, and removedprotection to local industries, barriers to out-flow of funds and labour regulations. Theseprogrammes have had important consequencesfor the level of investment and development ofthe health services as well as for the majordeterminants of health.

It is not absolute shortage but rather the increas-ingly unfair distribution of resources that leads tothe current unacceptable levels of hunger, poorhealth and impoverishment. It is the globalisation ofthe inequitable and unsustainable market economythat underlies the overwhelming health, environ-mental and socio-political crises of our times.

a. Globalisation – some featuresNot only has the gap between the rich and the poorwidened dramatically in recent decades, butglobalisation has aggravated the hardships of thedisadvantaged millions. A host of laws, policies,and trade agreements have been introduced, whichadvance the planetary reach of TNCs and specula-tive investors. At the same time the rights and self-determination of the poor and relatively powerlesspeoples and nations are undermined.

What are some of the impacts of the current thrustof globalised economy?

P It has increased poverty, which is the singlemost important underlying factor causing illhealth.

P It has increased the disparities between the richand poor, further fuelling poverty and disrupt-ing the social fabric of individual nations.

P It is driven by short-sighted, growth-centredeconomic policies, which lead tooverexploitation and destruction of the environ-ment. This affects the health of people andthreatens the medium- to long-term life-supportsystems of our earth.


P It is directed by corporate interests with profitmaximisation as the primary objective.

P States are reluctant and unable to take responsi-bility for the common good. Greater debtburdens have not facilitated the economicsituation many states find themselves in.

P Global competition drives companies to cutcosts and places further pressure on individualcountries to ‘sell out’ their environment andlabour standards.

P Growing unemployment and underemploy-ment leads to further social problems and illhealth.

P Weakened tax bases, forced decreases in importtariffs and lifting of quantitative restrictionsobstruct countries’ ability to provide basicsocial services. Severe cut-backs in the socialand health sectors have a direct effect on thehealth status of people.

P This globalised ‘casino economy’ is increas-ingly removed from any connection with placeand reality, and is characterised by enormousfinancial flows and speculation. Profitmaximisation for shareholders is a drivingforce. Ironically, a significant proportion of theshareholders is made up of ordinary workers inthe North, who through the speculation of theirpension funds, accelerate the trend towardscost-cutting—thereby risking their own jobsand social security.

Further features of the globalised economic ordercan be identified :P The emphasis on free trade has increased the

‘unfair trade’ between developed and develop-ing countries. This has seen the devaluation ofThird World currencies— supposedly imple-mented to increase developing countries’ exporttrade, but instead having the effect of depress-ing the wages and standard of living of vastsegments of the population around the world.

P There is an increase in the rate of unemploy-ment—seen even in developed countries.Increasing numbers of people, especially theyoung, are unable to find jobs in the formalsector—which traditionally providedsecurity and a sense of stability. As aconsequence, large numbers of people,including 100 million children, areforced to seek employment in theinformal sector.

P An increase in the external debt ofThird World countries has meant thata significant share of their income isused to pay back their debt with oftencrippling interest rates. This hasresulted in an increased flow ofresources from the Third to the firstWorld.

P The implementation of economic reformprogrammes such as SAPs has destroyed thedomestic economy, limited governments’positive participation in their economies byreducing their employment capacity as well aspublic spending in critical social services suchas education and health.

P Human and environmental costs are secondaryin the thrust to privatise virtually all sectors ofproduction and public services. More value isplaced on private profits for the fortunate fewthan on public goods for everyone.

P It has increased the unit cost of development inpoorer countries thereby increasing corruptionand dependency.

P For the marginalised population, all theseincreased hardships have led to widespreaddeterioration in physical, mental, social andenvironmental health.

As ‘big industry’ increasingly shapes the world,policies that protect human well-being are system-atically eroded. The production of harmful technol-ogy, goods and products, in it a crime againsthumanity has proliferated out of control. Theworld’s three largest industries—weapons, illicitand addictive drugs, and oil—all promote theirproducts in ways that contribute to physical andstructural violence. These industries take an enor-mous toll on human and environmental health. Thetobacco, alcohol and pesticides industries, amongothers, have powerful political lobbies, ensuringthat weak governments subsidise rather thanseriously regulate or restrain them.

The military industry is very large and profitableand depends on conflicts and violence, which areso prevalent. In 1999 it was worth USD 745 billiondollars, USD 125 dollars per capita. The poorerregions spend the highest percentage of their GNPon the military, many times their health or educa-tion expenditures.6

On the other hand, new international organisationssuch as the WTO are increasing their influence,through various agreements, and having an ad-


verse impact on health, food security and theenvironment. The Trade-Related IntellectualProperty Rights (TRIPs) regime that, among otherthings, allows patenting of seeds will pose a threatto genetic resources, sustainable agriculture, foodsecurity and the well-being of farmers. Increasingpatent protection will lead to increasing prices andreduced access to medicines, which will continue tobe under monopoly control.

TNCs are promoting and dumping harmful prod-ucts, processes and technologies such as tobacco,asbestos, pesticides, dioxin, genetically manipu-lated foods and genetically engineered seedswithout adequate biosafety trials and dumping oftoxic waste. In particular, they are releasing toxic,chemical and nuclear materials in Third Worldcountries where they benefit from weak govern-ments and weak prohibitive legislation.

What is the impact of globalisationin your community?

2. The social environmentAs a result of these economic and political factors,there is an increasing erosion of the social fabric ofsocieties, institutions, communities and families.

a. Weakening of institutionsOne important trend resulting from the currentglobal socio-economic development model is theweakening of national public institutions withforced rapid privatisation of services and disinvest-ment of public sector institutions, which is increas-ing unemployment, creating social and financialinsecurity and decreasing government control andaccountability. At a time when governments need toincrease their capacity to create and enforce mecha-nisms that will ensure equity and participation,governments around the world are in fact losingtheir capacity to fulfil their basic responsibilities ofensuring security and promoting equity. Increas-ingly governments’ roles and responsibilities arebeing transferred to the private sector, corporationsand other national and international institutions,which are not transparent or accountable to anyone.

Other traditional institutions, such as politicalparties and trade unions, are under increasingstress. People no longer feel that political partiesrepresent their interests, and they are disillusionedwith the electoral processes—this is at a time whenthere is an increasing need and demand around theworld for greater democracy and participation.

Trade unions are under threat of losing their con-stituencies and the confidence of workers. This ismainly as a result of the current trend towardsindividual, productivity-oriented labour relations,which do not foster workers’ organisations and inmany instances represses them. At the same time

there is a newtrend whereworkers’ organi-sations indifferent coun-tries are organis-ing and ad-dressing issuesrelated tointernationalagreements,taking a labourperspective,supporting eachother andchallenging theunjust corporatedecisions.

There is increas-ing use ofmoney anddisinvestment ofpublic sector institutions, which is increasingunemployment, creating social and financialinsecurity and decreasing government control andaccountability. Corruption is endemic in all kindsof institutions, playing a further role in weakeningtheir legitimacy.

b. Employment and UnemploymentExpansion of trade does not always mean moreemployment and better wages. In the OECD coun-tries, employment creation has lagged behind GDPgrowth and the expansion of trade and investment.Globally more than 35 million people are unem-ployed, and another 10 million are not taken intoaccount in the statistics because they have given uplooking for a job. Among youth, one in five isunemployed.

In both poor and rich countries, the neoliberalmodel, with its economic and corporate restructur-ing and dismantling of social protection, havemeant heavy job losses and worsening employmentconditions. Jobs and incomes have become moreprecarious. The pressures of global competitionhave led countries and employers to adopt moreflexible labour policies and work arrangementswith no long-term commitment between employerand employee.

c. The role of corporate mediaThe promotion through corporate media of unethi-cal advertisement and unhealthy lifestyles havedisplaced indigenous, natural nutrition and cul-tural practices (e.g. bottle-feeding versus breast-feeding, fast foods replacing nutritious and cheaperlocal foods). In addition media is also promotingtobacco, alcohol and drugs.

Through unethical and aggressive promotion

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corporate media is presenting women as sexobjects, which has a negative effect on their self-esteem and image, is degrading, worsening dis-crimination and increasing violence.

d. Conflict, violence and warWar and conflict over control of resources arepresent in every region of the world (e.g. SierraLeone over diamonds, Iraq over oil). Intoleranceand increasing conflicts over ethnicity and religionhave divided communities and created war anddestruction, especially hurting and maimingwomen and children. The dislocation ofpopulations due to migration for economic, politi-cal, and ethnic conflicts has a direct influence onthe health and well-being of millions of people andan important number of people are disabled as aresult of land mines explosions.

Violence in all its forms is present in every society.We are witnessing an increase in domestic violence,human trafficking, children soldiers and drug-related violence.The sex industry has expanded as women andchildren are pushed into prostitution to try toensure the survival of their families and depend-ants. Sexually transmitted diseases and AIDS aremost common where there is the most exploitativegap between men and women.

e. The familyAdverse socio-economic conditions have alteredtraditional family structures all over the world.There is an increase in the number of divorces andsingle parent families, without the required socialand economic structures to support them. This isespecially taxing on women who find themselvesunder greater stress as they are left with the respon-sibility of caring for the home, and trying to eke outa living.

f. EducationEducation inequalities—in access, attendance,quality of teaching and learning outcomes—per-petuate income and social inequalities in develop-ing countries across the world. Poor children attendpoor schools and have less opportunity to completetheir basic education or go on to secondary andhigher education.

Misallocation of resources, inefficiencies or lack ofaccountability are prominent attributes of theorganisational structure of education in developingcountries, contributing to the poor state of educa-tion.

Is the situation described aboverelevant in your setting?

Are there other important social factorsin your community and country?

What are people and governments doingto address them?

3. The physical environmentAlthough the destruction of the environment is notnew to the present era, it is reaching unprecedentedlevels. Fuelled by a runaway global economicsystem, the resulting environmental deteriorationthreatens to harm the planet’s ecosystems irrevers-ibly. If not urgently countered, global environmen-tal changes will endanger our entire social andeconomic systems, with disastrous effects on thehealth and even survival of our own and manyother species.

a. Environmental threats to healthEnvironmental threats to people’s health are bothdirect and indirect.

Direct threats include exposure to toxic substances,contaminated water, polluted air, radioactivity andenvironment-induced natural disasters. Newtechnologies such as genetically modified foodsand nano-technology can compromise health andupset ecosystems.

Indirect threats include environmental degradation,for example, food shortages due to the changingclimate that damage both farmland and forests.There is an increase in health problems among‘environmental refugees’ in situations where peopleare forced off their homelands because of thedestruction of local environments; and people arebeing killed or maimed in wars fought over scarcenatural resources.

Environmental problems may have immediate ordelayed effects on health.

Immediate effects are easier to recognise. For example,people get sick from drinking chemically andbiologically polluted water or breathing air pollutedby poisonous chemicals, or starves because farm-lands have been destroyed with crop failure, pestsand climate changes.

Delayed effects are often more difficult to link to theircauses. For example, there is an increase in theincidence of cancer believed to be caused fromexposure to pesticides, carcinogenic chemicalsubstances, or low levels of radiation used inindustry and food-processing. These threats havean erosive effect on the health of the people of ourplanet.

Changes in the environment pose some of the mostalarming threats to human health. Changes in theworld’s climate caused by global warming are a threatespecially to islands and coastal areas, where in-creased incidence of droughts and floods could killmillions of people and cause new health epidemics.In the future whole regions may lose their capacity togrow food.

Disputes over resources have already lead to regionalwars (for example, oil in Iraq, Nigeria and Somalia,forest in the Amazon and Sawara, Diamonds in Si-erra Leone). In the near future, ownership of biologi-


cal wealth through unjust international regimes ofTRIPS can also lead to conflict.

b. A crisis of justiceThe environmental crisis is a crisis both of natureand of justice. Although the growing population ofthe Third World is often blamed for the destructionof the environment, the industrial societies in theNorth and the elites of the South are in fact themajor culprits. On average, a person in the UnitedStates consumes about 50- 100 times as muchenergy, water and non-renewable resources, andleaves behind 50-100 times as much garbage andpollutants, as does a person in Bangladesh. Yet theBangladeshis will suffer much more from environ-mental imbalances.

Millions of people’s health will be at risk as theclimate changes and global warming causes sealevels to rise, largely a consequence of affluentlifestyles in the North. In both the North and theSouth, the poor and marginalized will suffer themost. They have the most environmentally hazard-ous jobs, live closest to waste dumps and pollutingindustries, and are the first to become environmen-tal refugees as their livelihoods are destroyed.

The need for GNP growth and industrial develop-ment in the South is undisputed. However theseprocesses need to be based on environmentalregeneration rather than continued environmentaldegradation, to ensure the sustainability of theplanet and the well-being of the populations in theSouth.

c. Underlying causesOur current environment and health crisis is associ-ated with the following:P The misleading view of progress and develop-

ment as a universal, linear pattern of societalchange where different societies all take part inthe same race towards industrialisation andever-increasing wealth;

P The notion of nature as an inert, mechanicalconstruction, existing only to be extracted andexploited for human short-term benefit;

P The failure of economics to base its theories inan environmental context and to recogniseecological constraints;

P The unsubstantiated belief that neoliberalism,corporate concentration and unchecked interna-tional trade policies will lead to ‘trickle down,’fairer consumption patterns and the eradica-tion of poverty.

4. The health sectorHealth services today are inaccessible,inaccessible,inaccessible,inaccessible,inaccessible,unaffordable, inequitably distributed and inap-unaffordable, inequitably distributed and inap-unaffordable, inequitably distributed and inap-unaffordable, inequitably distributed and inap-unaffordable, inequitably distributed and inap-propriatepropriatepropriatepropriatepropriate in their emphasis and approach.

Throughout history societies have responded toillness and disease by organising their healthservices, with different approaches, practices andstaffing. In most countries traditional and Westernmedical systems have coexisted and people haveused them either for different purposes, or in anarrangement that suits their needs and resources.People make the initial decision of what system touse depending on their culture, perceptions andassessment of either system’s capacity to solve theirproblems, as on the accessibility of both systems.

The particular organisation of a system depends onthe mix of human, financial and material resources.In most countries the Western medical model isapplied in the public and private sectors. The extentand level of care provided by different countriesrange from universal public services (Cuba), univer-sal health insurance (most countries in Europe,Canada and Australia), to a variety of social secu-rity schemes (Mexico) or of private schemes(United States).

There are innumerable examples of peoples’ strug-gles for health over the last century, with differentcountries and communities evolving their ownsystems to manage illness and health. Community-based Primary Health Care (PHC) programmesdeveloped by communities and trained communityhealth workers (CHWs) have been very importantin the improvement of the health conditions ofmany rural communities around the world.

The effectiveness of these experiences were recog-nised and became the basis of the 1978 Alma AtaDeclaration, where comprehensive PHC wasaccepted and endorsed by all the WHO andUNICEF member states. The prime basis was theacknowledgement that we need to act upon theunderlying determinants of health, including thosepolitical and economic factors that determine thehealth status of people and populations.

The economic policies of the 1980s led to the imple-mentation of structural adjustment programmes(SAPs), which increased the pressure on govern-ments to decrease their participation and commit-ment to universal health services, limited theimplementation of comprehensive PHC and pro-moted a wave of health care ‘reforms’.

The widespread efforts and experiences of PHCprojects in the 1970s and early 1980s were boycottedor ignored, and the projects themselves were underpressure to abandon their comprehensive approach

In your opinion, what are the environmental threatsto your community?

What is producing them?Is this an issue for you or your organisations?

Is something being done?


in favour of more ‘practical and feasible’ strategies,i.e. selective primary health, child survival, otherlimited targets and now vertical programmespushing limited agendas.

Severe cuts in national budgets for health resultedin the deterioration and often the collapse of serv-ices at many levels. These conservative fiscalpolicies, with inadequate resource allocations forcapital and recurrent costs, resulted in deterioratinghealth facilities, shortages of equipment, drugs andtransportation, reduction in the numbers of healthpersonnel, and deterioration in their performanceas a result of worsening working conditions.

The funding cuts brought about by certain compo-nents of Health Sector Reform, notably decentralisa-tion and privatisation of services, concentratedhealth services in urban and affluent areas. Whiledecentralisation of health care management hasbeen promoted as a mechanism to improve theefficiency and accountability of health services, ithas, in effect, frequently become a mechanism forfurther withdrawal on the part of central govern-ment from their financial responsibilities.

Health Sector Reform has promoted privatisationthrough such mechanisms as public–privatepartnerships and other approaches to health-financing. These initiatives, together with the lack ofhuman and other resources in the underfundedpublic sector, have led to the rapid growth of self-medication and a growth of the private healthsector. Large numbers of poor people have been leftwith little or no access to any health care.

In this context however, many communities havestrengthened or developed their programmes andthere are examples of CHWs working in non-governmental community health programmeswhich are addressing people’s needs.

What is your experience ofprivatisation of health services?

a. Health care as a commodityHealth care has been converted from a basicright into a product that can be sold or ex-changed for profit, resulting in an emphasison the curative aspects of health at the ex-pense of the preventive and promotivedimensions of health care.

The dominance of curative care has beenreinforced by the commercialised andpharmaceuticalised health care industry, themedicalised education of health professionalsand a renewed emphasis on “cost-effective”health interventions.

The past decades have witnessed an increase in theinfluence of the health care industry that produces,for example, pharmaceuticals, medical equipmentand baby food. Funding for research on ‘diseases ofpoverty’ is minimal compared to that allocated forthe study of ‘diseases of affluence’ in the industrial-ised world.

The medical equipment industry has mushroomed.Although this has facilitated the diagnosis andtreatment of some conditions, it has driven upmedical costs, has further inflated the ‘magic bullet’myth of curative care and rendered services lessaffordable to the poor—or put them out of theirreach altogether.

Health professionals’ education remains domi-nated by a biomedical approach (treatment ofillness rather than promotion of health). With fewexceptions, training programmes have failed tointegrate the principles of public health and PHCinto their core curricula. PHC has at most been asmall component of a marginalized public healthcourse, rather than informing the whole curricu-lum.

b. Problems in the implementation of PHCThe institutional mechanisms needed to implementcomprehensive PHC have been relatively neglected.Insufficient thought, resources and energy havebeen allocated to important aspects of PHC, such asthe development of intersectoral action and com-munity involvement. Little effort has been made toincorporate the lessons learned from the innovativeexperiences of a multitude of community-basedhealth projects. The dominant technical approach ismedically driven, vertical and top-down andreflects in the organisational structuring of manyministries of health and the WHO itself.

Many PHC projects today focus on medical andtechnical interventions, such as the child survivalinitiative, which mainly promotes two ‘technologi-cal fixes’—immunisation and oral rehydrationtherapy.

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This trend has been reinforced recently by newmethodologies designed to promote cost-effective-ness in health. The development of DALYs (disabil-ity-adjusted life years) as an index to quantify theburden of disease, and to cost the effectiveness ofcertain interventions, has resulted in the shift offocus towards selected medical technologies at theexpense of broader social interventions. The DALYsapproach, promoted by the WB, and uncriticallyembraced by WHO, has also in effect devaluedimportant aspects of health care, such as caring,which cannot be easily measured for cost-effective-ness.

c. Health care as an instrument of socialcontrol

Health care is increasingly used as a subtle andwidespread instrument of social control. Central tothis is the ideology of medicine, which mystifies thereal causes of illness, often attributing disease tofaulty individual behaviour or natural misfortune,rather than to social injustice, economic inequalityand oppressive political systems. This is particu-larly apparent in situations of war and politicaloppression.

Examples of such victimising and conservativeapproaches to health care include the heavy-handedpromotion of family planning, in isolation fromsocial development, as a means of populationcontrol. Further oppressive forms of health educa-tion, which tend to blame ill health on people’s‘lifestyles’ while neglecting the social determinantsof their ‘bad habits’ and patterns of consumption,are dominant.

We would like to know how accessiblehealth services are in your community andif you think there are problems in the way

they are organised and managed.Are the services comprehensive?

Does your community feelthey address your needs?

What is the role of health workers?What are their work conditions like?

1. Movements for change

The dimensions and complexity of the majorproblems affecting human and environmentalwell-being today are hugely different from the

situation that confronted past generations, and farmore difficult to challenge. There was a time whenpeople in one part of the world could come togetherand take a stand against unfairness or injustice atthe local or even national level and succeed. Today,the forces that threaten human and environmentalwell-being are increasingly global, powerful,sophisticated and well coordinated.

New strategies are needed in the struggles for socialchange, to match the size and character of the forcesthat we are dealing with.

Actions for positive change need to be taken at thelocal, national and/or international level. Individu-als, groups of concerned people, progressive organi-sations, or networks of national or internationalcoalitions can take them. In today’s world, whereobstacles to personal and community well-beingare rooted in global policies and decisions, actionsto resolve injustices at the local level should leadpeople to join in more far-reaching global action forchange.

In the struggle for a common cause, there is a needto bring together:

P a wide range of diverse sectors and movements;P activists from all nations;P concerned people of different races, classes,

castes, sexual preferences, ages and profes-sions;

P people and groups whose work for change isfocused at different social levels: individual,family, national and global;

P NGOs, labour unions, women’s and humanrights groups, watchdog groups, environmen-talists, health promoters, community healthworkers, progressive political parties, socialactivists in diverse fields, eco-economists,peace/anti-war and anti-nuclear groups,groups working for universal health coverage.

GLOBAL MODEL OFDEVELOPMENT

THE WAY FORWARD

andchallenging the current

INEQUITABLE

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As the worldwide crisis deepens and more andmore people from all positions on the social spec-trum begin to realise that the current global eco-nomic system has lethal flaws, the groundswell forchange is gaining momentum.

There is an urgent need for a new, alternative visionof development—one that promotes human andenvironmental well-being.

Such a vision is taking shape among many people’sorganisations around the world. Despite theirdiversity, certain common threads stand out. Theseinclude:

P an attempt to increase public participation tocounter the concentration of economic, politicaland corporate power;

P an effort to establish healthy communities;P reshaping the global economic order to ensure

environmental sustainability, equity and socialjustice;

P the call for a closer and more spiritual relation-ship with nature and communities; and

P a commitment to collective solutions thatmaintain considerable individual freedom.

The quest for sustainable societies calls for drasticchanges in the current world order. It requires theformation of strong broad-based people’s move-ments. All movements (health, environment, social,women, among others) must join forces and be seenas part of the same, overall movement for socialchange, social and gender justice.

We need to focus on a wide range of issues includ-ing corporate responsibility, election financingreforms, social and gender justice, foreign debtcancellation, corporate accountability, participatorydemocracy, disability and elderly rights, progres-sive education, biodiversity and community healthcare.

2. Types of Action for ChangeWhat types of action are available and have beenused successfully by individuals and movementsworking for change? The possibilities are numerousand have proven to be effective time and time again.

P Actions to counter misinformationcounter misinformationcounter misinformationcounter misinformationcounter misinformation and raiseawareness;

P activities that help empower peopleempower peopleempower peopleempower peopleempower people to assesstheir needs without mystified prescriptions andto take action themselves;

P activities to promote better coping strategiescoping strategiescoping strategiescoping strategiescoping strategies,provide servicesservicesservicesservicesservices and develop local alternativealternativealternativealternativealternativesolutionssolutionssolutionssolutionssolutions to immediate problems;

P actions that drastically improve networkingnetworkingnetworkingnetworkingnetworkingand information-sharing;

P actions that promote solidaritysolidaritysolidaritysolidaritysolidarity between andamong people’s organisations;

P exerting and multiplying political pressurepolitical pressurepolitical pressurepolitical pressurepolitical pressure tocounter policies and decision-making that onlybenefit the few;

P pressure governmentspressure governmentspressure governmentspressure governmentspressure governments to involve pro-peopleorganisations in policy decisions;

P actions to claim rightsclaim rightsclaim rightsclaim rightsclaim rights and force those in powerto listen;

P promote self-governanceself-governanceself-governanceself-governanceself-governance by the people;P acts of civil resistance;P economic pressureeconomic pressureeconomic pressureeconomic pressureeconomic pressure through our roles as con-

sumers, taxpayers and holders of investmentfunds;

P advocate participationparticipationparticipationparticipationparticipation in social and politicalevents at all levels, from the villages, regions,nations and internationally;

The way forward is not only paved by granddesigns. There are many ways to contribute to ahealthier world. All meaningful gestures and smallpersonal acts of kindness and solidarity alsomatter. Because this is not enough, we have to worktogether to plan action that goes from the local tothe global level. That is our challenge for thisdecade and beyond!

Building on people’s positive traditions is animportant way forward. By way of example, in the


Punjab of India, even in the poorest communitiesthere are almost no street children. Families tradi-tionally welcome children into their homes, includ-ing those who are orphaned or abandoned.Through their tradition of helping one another inhard times, people living in extreme poverty findways of coping. But coping is palliative; overcom-ing and resolving the causes is the challenge.

Action for positive change can be approached inmany different ways, most often beginning with aparticular focus of concern, such as on environmen-tal issue, changes in health policies, globalisation,economic equity, fair trade, women’s rights, debtcancellation, or food security. It is important, tocoordinate activities and work together with organi-sations, movements, NGOs and community groupsthat have a track record of being ‘community-supportive’ at the local, regional or national level.

What follows is a selection of different approachesof taking action for change. With each approach, anexample of programmes, networks, or coalitionsworking in this field are given.

a. Awareness-raising and empowermentMisinformationMisinformationMisinformationMisinformationMisinformation has become the modern means ofsocial control. People—regardless of educationallevel—often have little knowledge of the injusticesdone to disadvantaged people. The media has away of keeping us strategically misinformed.

Only when enough citizens become fully aware ofthe issues will it be possible to place the commongood before the interests of powerful minorities.Creating such public awareness is an uphill strug-gle. More empowering forms of education andinformation-sharing are needed. Currently, schoolstend to teach history in ways that glorify those inpower, and follow teaching methods that instilconformity and compliance.

To counter this misinformation and to mobilisepeople for a more equitable society, we need alter-native methods of education and information-sharing that are honest, participatory, empoweringand that can bring people together as equals whocan critically analyse their reality and take unitedaction.

A few examples of alternative periodicals thatprovide examples of watchdog initiatives andgrassroots action for change include:

Multinational MonitorYES, A Journal of Positive FuturesThird World ResurgenceResurgenceThe New InternationalistThe NationDollars and SenseThe ProgressiveHealth for MillionsZ MagazineMother JonesHAI BulletinMedico Friends Circle BulletinJournal of Medical ethicsBeejaHealth Action

TelemanitaTelemanitaTelemanitaTelemanitaTelemanita is an NGOworking in Mexico, thathas been trainingwomen to use videotechnology to maketheir own documenta-ries, promotion andtraining materials.

Project Piaxtla in Mexico Project Piaxtla in Mexico Project Piaxtla in Mexico Project Piaxtla in Mexico Project Piaxtla in Mexico has developed differenteducational methods for information sharing. Sincethe mid-1960s, the village health promotersworking in this rural area have developedinteractive teaching methods to help peopleidentify their health needs and work together toovercome their problems. As a result, resourcebooks such as Where there is no doctor, Helpinghealth workers learn and Nothing about uswithout us (by David Werner) are now used aseducational tools worldwide.

Another method developed by this project andlater shared with other organisations in CentralAmerica and Asia is the Child to Child Child to Child Child to Child Child to Child Child to Child pro-gramme which works with school-age childrenlearning ways to protect the health of otherchildren. Children learning through experience dothat. Children conduct their own surveys anddiscover answers for themselves; they learn towork together to help each other.

Further, we have to build on global solidarity andfind ways to communicate truthfully and directly.Alternative mediaAlternative mediaAlternative mediaAlternative mediaAlternative media, including the Internet, for thosewith access to it, provide avenues to be exploited.Storytelling, street theatre, awareness-raisingcomics and novellas, as well as community radioand TV, and the alternative press, offer vital com-plementary outlets that we need to use moreefficiently.


b. Activities that empower people to take actionCommunity-based health programmesCommunity-based health programmesCommunity-based health programmesCommunity-based health programmesCommunity-based health programmes and commu-nity initiatives in health care planning and devel-opment in various countries have brought peopletogether to take back control over their health andraise awareness of the underlying causes affectingtheir health. These programmes start with a com-munity diagnosis where it becomes clear to peoplethat inequality and the power structures thatperpetuate them are the root cause of ill health.

A community diagnosis/situational analysis is oneway of starting a group learning process —partici-pants are able to identify and prioritise health-related problems and other shared concerns.7

Gonoshasthaya Kendra (GKGonoshasthaya Kendra (GKGonoshasthaya Kendra (GKGonoshasthaya Kendra (GKGonoshasthaya Kendra (GK) ) ) ) ) is a communityhealth and development programme in Bangladesh,which began during the war for national independ-ence. Village women have become communityhealth workers and agents of change. Villagerscollectively analyse their needs and build on theknowledge and skills they already have.

Using this approach GK has expanded in manyareas. It has different training courses that enablewomen (in particular) to get non-traditional jobs.GK is currently working in 13 Districts and 21 sub-districts where it covers a population of over600,000.

The Centre for Information and Advise inThe Centre for Information and Advise inThe Centre for Information and Advise inThe Centre for Information and Advise inThe Centre for Information and Advise inhealth (CISAS) Nicaraguahealth (CISAS) Nicaraguahealth (CISAS) Nicaraguahealth (CISAS) Nicaraguahealth (CISAS) Nicaragua provides populareducation and communication services since 1983.Health work is seen as an instrument for communi-ties to develop and organise, think and transformtheir reality through collective action. It has differ-ent offices and documentation centres throughoutNicaragua and is active in the coordination ofregional primary health care networks. All its workhas a gender perspective.

Are you aware of any successful examples ofsimilar community-based initiatives?

Do you know of any story or case study that wouldillustrate or add to some of these points?Can you help us enrich this resource by

sharing your own experiences?

c. Networking and information-sharingEffective international South–North advocacynetworks on health and equity issues are beingformed. These link together existing and newlyestablished networks active in Public Health,bridging continents and connecting grassrootsmovements with people working on lobbying andadvocacy.

By joining forces we are able to consolidate astronger base to confront injustice and inequity.Strength in numbers not only gives us protectionbut also makes us a force to be reckoned with.Networking allows for cross-fertilisation of experi-ences, methods and ideas. People need to knowwhat efforts are being made elsewhere to opposeglobal forces and improve communities’ condi-tions.

Health Action International (HAI)Health Action International (HAI)Health Action International (HAI)Health Action International (HAI)Health Action International (HAI) lobbiesgovernments and international bodies (such asWHO) to formulate codes, pass resolutions anddevelop policies to ensure that people who needthem have access to safe, appropriate and afford-able medicines and these are used rationally. Itmonitors the unethical behaviour of industry andthe selling and promotional practices of drug compa-nies. It challenges international regimes of TRIPS andWTO.

The International People’s Health Council (IPHCInternational People’s Health Council (IPHCInternational People’s Health Council (IPHCInternational People’s Health Council (IPHCInternational People’s Health Council (IPHC))))) isa coalition of grassroots health programmes, move-ments and networks. It is committed to working forthe health and rights of disadvantaged people. Itstrives towards a model of people-centred develop-ment, which is participatory, sustainable and makessure that all people’s basic needs are met.

Self-employed Women’s Association (SEWA) Self-employed Women’s Association (SEWA) Self-employed Women’s Association (SEWA) Self-employed Women’s Association (SEWA) Self-employed Women’s Association (SEWA) inIndia is a Trade Union of women in the informalsector based on Gandhian ideology. It has linkedworkers rights with health and economic rights. Itsupports different services: training programmes,health services, loans, income generation pro-grammes and finds markets for women crafts.


Hundreds of progressive, social-action and environ-mental action ‘e-groups’ exist. For example:• EquinetEquinetEquinetEquinetEquinet is a mostly African discussion group of

activists working for fairer, more equitable dis-tribution of health and other resources.

• E-drugsE-drugsE-drugsE-drugsE-drugs is a group that shares information aboutessential drugs, relating to policy, product safety,quality and rational use of drugs.

• There are different e-groups dealing with HIV/AIDS both from the medical and the humanrights perspective.

d. Political pressure and resistanceWatchdog groupsWatchdog groupsWatchdog groupsWatchdog groupsWatchdog groups and organisations working forcorporate accountability and social justice have animportant role to play. A watchdog group is acollective of people who monitor the activities ofcorporations, government agencies or internationalinstitutions, and ‘blow the whistle’ (and encouragepublic protest) when these entities violate humanrights or endanger human or environmental well-being.

Watchdog groups are proving influential in curbingthe abuses of big business, especially in the absenceof needed government regulations. Often, theirmost important weapon is to raise public awarenessand outrage, motivating people to take action.Where the mass media is unsympathetic to theissues raised, we need to utilise the alternativepress, radio and community TV.

Bank WatchBank WatchBank WatchBank WatchBank Watch monitors and reports on the policiesand projects of the international financial organisa-tions,,,,, especially the World Bank.

The ‘50 Years is Enough’ alliance‘50 Years is Enough’ alliance‘50 Years is Enough’ alliance‘50 Years is Enough’ alliance‘50 Years is Enough’ alliance has involved over200 organisations around the world and demandedthat the World Bank stop its policies and pro-grammes that favour the interests of big business atthe expense of human and environmental well-being. In the United States, 50 Years is Enoughlobbied the government to restrict funding of theWorld Bank and International Monetary Fund untilthey improved disclosure, environment, andworkers’ rights policies.

The International Forum on Globalisation International Forum on Globalisation International Forum on Globalisation International Forum on Globalisation International Forum on Globalisation, withcitizen representation in both the First and ThirdWorld, is one of the leading collectives of activistsattempting to raise public awareness on the healthand environment-damaging aspects of the globaleconomy, as well as pushing for corporate account-ability. It has successfully campaigned with othersagainst MAI and contributed to it being squashed.

The International Breast Feeding Action NetworkInternational Breast Feeding Action NetworkInternational Breast Feeding Action NetworkInternational Breast Feeding Action NetworkInternational Breast Feeding Action Network(IBFAN)(IBFAN)(IBFAN)(IBFAN)(IBFAN) is involved in health education about theimportance of breast-feeding; at the internationallevel, it campaigns to stop the unscrupulous promo-tion of bottle-feeding by transnational corporations.IBFAN spearheaded the world-wide boycottboycottboycottboycottboycott of theNestle corporation and stood behind the Interna-tional Code on breast milk substitutes introduced byUNICEF, WHO and the United Nations and en-dorsed by virtually every nation except the UnitedStates. At the national level, to give the code legisla-tive support, the government of Papua New Guineapassed a law prohibiting the sale of baby bottles andinfant formula except by prescription. What startedout as organised action by a group of concernedwomen has gone a long way toward raising publicconsciousness and opposing the profit-before-peoplebehaviour of giant transnationals.

Electronic networkingElectronic networkingElectronic networkingElectronic networkingElectronic networking for change needs, whereverpossible, to be exploited more decisively as a usefulavenue for dialogue between grassroots groupsengaged in popular struggles. Currently, however,computers and the Internet are available to only 1%of the world population.

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Advocacy and lobbyingAdvocacy and lobbyingAdvocacy and lobbyingAdvocacy and lobbyingAdvocacy and lobbying can play a particularlyimportant role in the struggle to improve policiesboth at the national and international levels. In thisarea, efforts are made from the local to the interna-tional level.

An example is the campaign of the Multinational Multinational Multinational Multinational MultinationalResource Centre Resource Centre Resource Centre Resource Centre Resource Centre and the Physicians for SocialPhysicians for SocialPhysicians for SocialPhysicians for SocialPhysicians for SocialResponsibilityResponsibilityResponsibilityResponsibilityResponsibility against the burning of hospitalwaste, an industry that contributes to poisoning theglobal atmosphere with dioxins, mercury, and otherdeadly and cancer-causing poisons. They areprotesting against the World Bank for promotingthe use of these medical waste burners in healthsector projects in at least 20 countries. A Senegaleseanti-incinerator network says of the World Bank’shealth sector projects in Africa, ‘We want funds totreat us and not to poison us’.

The Zapatista uprising Zapatista uprising Zapatista uprising Zapatista uprising Zapatista uprising in Chiapas, Mexico, waslaunched by a handful of impoverished tribalpeople on 1 January, 1994, the day that the NorthAmerican Free Trade Agreement (NAFTA) cameinto effect. The Zapatistas did not want to over-throw the Mexican government, but to make itrespond to the people’s most basic needs for land,food and health care. At first, the Mexican govern-ment tried to crush the ‘mini-revolution’ by brutalmilitary might. But through their well-plannedcommunications network (including the Internet)the Zapatistas sent an SOS to people’s organisa-tions, progressive NGOs and news reportersaround the world. To a large extent it was theinternational outcry that forced the Mexicangovernment to hold back its assault and enter intonegotiations with the Zapatistas. While the resultsso far have been far less than hoped for, at leastsome of the laws protecting the rights of smallfarmers were partially reinstated. The strugglecontinues to this day and international supportcontinues to be vital to its success.

Advocacy efforts in the area of trade and invest-ment are increasing in order to oppose threats toequity-oriented health policies and systems, such asthe current developments in the areas of servicesand government procurement under the WTO andthe plans to establish a multilateral investmentagreement. Advocacy can be focused on specific,local issues or can take the form of large interna-tional campaigns.

An example is the Jubilee 2000Jubilee 2000Jubilee 2000Jubilee 2000Jubilee 2000 campaign to solvethe problem of Third World debts. Jubilee 2000 is acoalition of religious and secular groups from allaround the world working on this issue.

Another example is the proposed tax on interna-tional financial transactions: the Tobin taxTobin taxTobin taxTobin taxTobin tax. Theproposal is to use the proceeds from such a tax tomeet basic human needs. While such a tax would dolittle to transform our unjust and ultimately unsus-tainable free market economy, it could at leastprovide huge proceeds to help redress the damage.

One of the most effectivemeans of gaining publicattention and support foran alternative position areorganised mass demon-organised mass demon-organised mass demon-organised mass demon-organised mass demon-strations, protests andstrations, protests andstrations, protests andstrations, protests andstrations, protests and‘alternative assemblies’‘alternative assemblies’‘alternative assemblies’‘alternative assemblies’‘alternative assemblies’around key internationalaround key internationalaround key internationalaround key internationalaround key internationaleventseventseventseventsevents. This is especiallyappropriate when theevent is staged at the sametime and in the sameplace as a major summitor meeting of the domi-nant system and if itincludes a strong, well-organised educationalcomponent.

The Battle in Seattle Battle in Seattle Battle in Seattle Battle in Seattle Battle in Seattle in1999 was a massiveinternational protestagainst the WTO summitin Seattle. It was a turningpoint in terms of showingthat democracy hasavenues other thanelections, and that agroundswell of well-organised and well-informed people can makethemselves heard. All the activists in the Battle inSeattle recognise that while the event itself wasimportant, it will be the continuity of follow-up thatcan make a lasting difference. A follow-up demon-stration took place in Washington DC coincidingwith the semi-annual meetings of the World Bankand the International Monetary Fund in March 2000.

During the UN Social Summit in Denmark, pro-gressive NGOs from around the world held aparallel Summitparallel Summitparallel Summitparallel Summitparallel Summit nearby, gave lectures and leddemonstrations to counter the economicglobalisation promoted by corporate interests andthe World Bank. An ‘Alternative CopenhagenDeclaration’ was drafted and endorsed by hundredsof NGOs.


e. Mobilisation of consumers in internationalboycotts

Increasingly, consumers are mobilising and boy-cotting companies and initiatives that are unfair orendanger the health of the people and the environ-ment. These involve actions from the personal to theglobal level and have had an important impact oncompanies’ behaviour.

f. AdvocacyA strong advocacy movement has to be one of theresults of the PHA. This network will be able toexpress and demand changes from the local to theinternational level.

At the local level: we will present recommendationsand experiences of the PHA to decision-makers atthe local and municipal levels. We will look forsupport and endorsement of the PCH by networks,people’s organisations and concerned individuals.

At the national level: we will support the advocacyefforts of local, national and international people’sorganisations in the form of lobbying, campaigning,presentations, discussions, seminars, etc. Suchefforts can be directed at a broad range of nationalinstitutions, organisations and companies that haveimportant impacts on health, as well as at thenational offices of targeted international and re-gional institutions and organisations present in thecountry.

At the international level: we will join together withcommunity health-oriented organisations which arelobbying and putting pressure on internationalorganisations. For example, WHO, other UNagencies, funds and programmes, multilateral andregional development banks will be lobbied toensure they promote and finance comprehensivePHC, assess the effects of SAPs and health carereforms. We will also lobby international trade andfinancial institutions and TNCs to develop policiesthat take into account and minimise the health andenvironmental consequences.

This section has given just a handful of examples.We cannot begin to do justice to the innumerableconcerned groups that have taken and are takingaction to fight for the people whose rights are beingviolated. We only want to stress that the struggle isnot new. But it needs more strength. PHA joins infilling a space in the defence of people’s health. Weare taking on a big responsibility, we know. But wealso know that there are thousands of you out therewho feel exactly as we do. This initiative can bringall of us together. Only by acting together do wehave the chance to succeed.

The Chipko ‘hug the trees’ movementChipko ‘hug the trees’ movementChipko ‘hug the trees’ movementChipko ‘hug the trees’ movementChipko ‘hug the trees’ movement in India arosewhen contractors coming to cut the village trees of theGarhwal hills were resisted by women led by GauraDevi. The women hugged the trees preventing themform being cut. Later women in Nabi Kala in the DoonValley fighting to safe guard their water resources andfields from lime stone quarry contractors used the sameway of resistance.

Chipko originated 300 years ago in Rajasthan whenBishnoi community members hugged the trees toprotect them from being cut by the King’s men andwere killed.

Militant resistance to the Chico damMilitant resistance to the Chico damMilitant resistance to the Chico damMilitant resistance to the Chico damMilitant resistance to the Chico dam. . . . . In theCagayan valley in the Philippines, the Kalinga tribalpeople plant rice on the steep slopes of the ChicoRiver gorge, which they have laboriously terracedfor thousands of years. They were not consultedwhen, in 1967, the IMF and WB, in collaborationwith transnational companies, started to build adam that would flood their ancestral homeland.The people’s formal petitions were unheeded. Sothey resorted to civil disobedience led mostly bywomen. Repeatedly they removed the tents andequipment of the dam-building crews, and barri-caded the roads. Women lay down on roads toprevent entry of big equipment. But soldiersforcefully removed them and the dam-buildingbegan. In desperation, they dynamited the dam.Finally, in 1987, after 20 years of active resistance, thegovernment called a halt to the dam-building.Reportedly, this was the first time that an IMF–WBfunded project was successfully stopped by militantopposition on the part of the people.

There are many examples of acts of resistanceacts of resistanceacts of resistanceacts of resistanceacts of resistance,when people organise and take a stand for thecommon good that can lead to public outrage andsometimes to an eventual retracting by the authori-ties.

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examples

Drawing on this wealth of experiences, meth-ods and strategies promoting change, whatshould the PHA Action PlanPHA Action PlanPHA Action PlanPHA Action PlanPHA Action Plan for a healthier

world look like? What are the important points weshould focus on? We invite you to add to this first,rough version of an action plan, which we presentbelow. We hope that in the time leading to thePeople’s Health Assembly event in Dhaka, therewill be many contributions from all corners of theworld.

Living up to the political challenges toLiving up to the political challenges toLiving up to the political challenges toLiving up to the political challenges toLiving up to the political challenges topeople’s health (actions needed)people’s health (actions needed)people’s health (actions needed)people’s health (actions needed)people’s health (actions needed)

P Document the consequences of the SAPs andthe international trade agreements on the healthand well-being of people, their working condi-tions and the environment.

P Reassess the neoliberal economic model andpropose viable alternatives.

P Lobby to place health and well-being as theobjective of development and its measurementas an indicator of success or failure of economicpolicy.

P Lobby to make human and environmentsustainable development the objective of eco-nomic policies placing it at the centre of thediscussions on restructuring the Bretton Woodsinstitutions.

P Participate in the global campaign to promotefair terms of trade and combat and prosecutefinancial speculation.

P Support the implementation of a tax on finan-cial transactions (TOBIN tax) and debt cancel-lation.

P Establish a World Sustainable DevelopmentOrganisation with power to challenge the WTOenvironmental and social values, which arebeing violated by a short sighted, trade-orientedagenda.

P Support the proposals for a ‘People’s Chamber’in the United Nations.

P Advocate that all governments assume theirresponsibilities and abide international charters,declarations and conventions.

Living up to the social challenges to people’sLiving up to the social challenges to people’sLiving up to the social challenges to people’sLiving up to the social challenges to people’sLiving up to the social challenges to people’shealth (actions needed):health (actions needed):health (actions needed):health (actions needed):health (actions needed):

P Promote and support legislation and pro-grammes that empower women.

P Support indigenous people in their struggle forequality, forest, land and water rights.

P Participate in the fight against corruption, foraccountability and transparency.

P Develop support mechanisms for families,including childcare, women’s right to work andworkers’ right to motherhood.

P Promote alternative education systems thatfoster self-esteem, autonomous thinking andteaches life skills.

P Promote a code of ethics for the media

Living up to the environmental challengesLiving up to the environmental challengesLiving up to the environmental challengesLiving up to the environmental challengesLiving up to the environmental challengesto people’s health (actions needed):to people’s health (actions needed):to people’s health (actions needed):to people’s health (actions needed):to people’s health (actions needed):

P Lobby for the adoption of the precautionaryprinciple, which calls for restraint in cases ofuncertainty. Using this principle even thesuspicion of potentially negative consequencesof a technology or a policy should motivaterestraint and shift the burden of proof on thosein favour of it.

P Develop and implement mechanisms thatfavour relevant, environmentally and sociallyappropriate technologies while opposingdestructive ones (like genetically manipulatedfoods, genetically engineered seeds).

P Campaign for a redefinition of economic theorythat recognises environmental constraints.

P Support the introduction of tax shifts. Thesewould increase the tax on the ‘bads’ (e.g. energyconsumption, waste disposal, pollution, etc)while cutting the taxes on labour, therebycombating unemployment.

P Lobby for the development of accountingpractices that take into account both environ-mental and human well-being— both fornational accounting purposes, companies andpublic institutions.

P Promote the implementation of environmentalmanagement systems and their expansion toinclude health, environmental and social justiceconcerns.

P Lobby for adequate labelling of consumerproducts both in terms of their production and

examples of SPECIFIC ACTIONSfor a

AN EMERGING PHA ACTION PLAN

healthier world

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NotesNotesNotesNotesNotes

1 World Health Organisation. ‘World Health Report 1999’.Geneva, Switzerland.

2 UNAIDS. Report on the global HIV/AIDS epidemic- June2000.

3 World Health Organisaation. ”World Health Report 2000”.Geneva. Switzerland

4 UNDP. ‘Human Development Report 1999’. New York

trade (environmentally and socially appro-priate products) as well as their potentialharm (caution notices on foods and medi-cines).

P Advocate the curbing of over-consumption,affluent, unhealthy and unsustainable life-styles both in the North and the South.Industrial countries in the North should aim,for on average, a 10-fold reduction of theirconsumption and pollutions levels (‘FactorTen’).

P Advocate for the respect of the White paperson arms trade.

Living up to the health sector challenges andLiving up to the health sector challenges andLiving up to the health sector challenges andLiving up to the health sector challenges andLiving up to the health sector challenges andpeople’s health (actions needed):people’s health (actions needed):people’s health (actions needed):people’s health (actions needed):people’s health (actions needed):

P Assert at national and international levelshealth as a central objective for sustainabledevelopment.

P Lobby WHO to assume a stronger advocacyrole in the promotion of health as a develop-ment objective.

P Advocate to increase government investmentin health at national and international levels.

P Gather and disseminate information thatexpose inequities in health and developmechanisms to monitor the situation.

P Advocate for equity in health and health care.P Advocate for and promote policies and

projects that emphasise intersectoral actionsfor health.

P Demystify the causes of ill-health and pro-mote a better understanding of its socialdeterminants.

P Expose the real underlying structural causesof ill-health.

P Promote comprehensive Primary Health Careas a model to address priority health prob-lems and organise the health services.

P Promote community participation in plan-ning, management and evaluation of healthservices.

P Reassert the value of community-basedhealth workers (CHWs).

P Promote the use and dissemination of appro-priate health technologies.

P Foster changes in health personnel educationand health management making educationproblem-oriented and practice- based.

P Outlaw secret, not transparent or unethicalresearch.

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The paperThe paperThe paperThe paperThe paper you have just read presents anoverview of the situation and is very general. It isimportant to know if it is relevant to your specificsituation and, if so, in what way.

Please let us know what you would like to seeadded so that your situation is addressed.

We also hope you will contribute your experiencesin the form of case studies or stories that we can useto bring to the PHA specific analyses of differentsituations; this will stimulate others to find theirown solutions.

We are particularly looking for experiences orstories that make the links between local problemsand the global economic system, and that describepeople and communities’ empowering initiativesthat are already under way.

Send all your feedback by airmail or E-mail to:Nadine GasmanFuente de Emperador 28Tecamachalco C.P. 53950Estado de México. MEXICOTelephone: 52-52-510283Fax: 52-52-512518e-mail: [email protected]

Please send feedback by October 10, 2000. Be sure toidentify the name of your group, your country, thenumber of participants in your meeting, and themain characteristics of your group.

Also please send a summary of the points discussedduring your discussion of this draft framework.

Finally, please identify and send the main issues youwould like to see included in the People’s Charterfor Health.

F BACKEED

1999.

5 United Nations Research Institute for Social Development.‘State of Disarray’. 1995. Geneva.

6 SIPRI Yearbook 1999. Armaments, disarmament andinternational security. Oxford University press.

7 See, for example, the ‘But Why?’ game and the ‘Chain ofCauses’ exercise in PHA’s ‘Communication as if peoplematter’ background paper. These exercises can be used withspecific stories for better situation analysis.

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