In (silent) praise

Clowning around

Revisiting the Tasaday

Dancing down the Chao Phraya

Kaibigan

Health for all by year 2000

IMAGINE a health care system in which the frontlines in the war against disease are manned (and womanned) by community health workers at the village or neighborhood level.

These community workers, recruited from within the community itself and supported with a modest stipend, could also treat common diseases and provide first aid for injuries, while referring more difficult cases to the next levels of health care. The health workers would know where to refer these cases, and help with the paperwork to process claims from the government's health insurance agency, PhilHealth. Where needed, they would also know where to turn to for subsidized drugs.

Treating illnesses would actually form a minor part of these health workers' routine. Much of their time would be spent on preventive health, educating people on health care, organizing them for immunization campaigns, clean water, good nutrition and environmental sanitation. The health workers would check on pregnant mothers early enough, identifying high-risk cases and referring them to the appropriate hospital. We would not have cases like that of the couple with quadruplets, running around from one hospital to another trying to get admitted.

In cases of disease outbreaks, including new mystery illnesses such as SARS, the health workers would help to keep the communities calm, launching information and education campaigns while instituting measures such as quarantine with the full support of neighbors and friends.

What I'm describing is an ideal situation with primary health care operating. Until the 1990s, primary health care appeared on every other document from the World Health Organization (WHO), touted as the way to achieve "Health for All by The Year 2000," a slogan abbreviated to HFA 2000. This Friday in fact marks the 25th anniversary of the Alma Ata declaration, in which health officials from all over the world met, under the auspices of the WHO, to endorse primary health care and HFA 2000.

Alas, we've moved into the new millennium and we're far from achieving HFA 2000. In fact, I think we have moved backwards, with more people having less access to health care now than 20 years ago.

What went wrong here? Primary health care sounds simple enough, and countries throughout the world, including the Philippines, did initiate moves to implement such programs. In the Philippines, under Ferdinand Marcos, health officials claimed they trained more than 300,000 community health workers throughout the country -- a feat considered so impressive that one of our health ministers was awarded an international prize.

Today, we still have community health workers but they receive little support in terms of training and supplies. In many cases, the community health workers have become political pawns, selected by the incumbent mayor, only to be replaced if an opponent wins the next election.

This leaves Filipinos fending for themselves. Costs for going to the formal health care system -- from physicians' consultation fees to medicines -- are among the most expensive in the world, relative to local incomes. For most poor Filipinos, without health insurance coverage, the only recourse is to run to politicians, hoping to get a meager dole-out to buy a few days' supply of medicines.

Health education is a farce in the country, the mass media filled with misinformation, often planted commercials, posing as feature articles. The small budgets people have end up going to medicines and gadgets of unproven efficacy.

Primary health care failed partly because health professionals were unsupportive, claiming primary health care would produce "quack doctors." Of course, the real reason was that many interests were threatened, from hospitals that preferred to peddle expensive high-tech medicine, to drug companies fearful that people with health education would be more critical about their medicines.

Mostly, though, primary health care died because such programs received little political support. Politicians preferred to keep people ignorant and dependent, sponsoring an occasional charity medical mission as elections approached.

Other politicians saw primary health care as dangerous. Primary health care programs were actually quite threatening because as people learned more about health, they also became more politicized, recognizing that diseases were caused not just by germs but also by the polluting factories of big business, by government corruption, by low wages and poor working conditions. Good community health workers were, inevitably, good community organizers, people who were making people conscious that health itself was a basic human right that had to be fought for. No wonder that the few doctors who did support primary health care were harassed, accused of being subversives. One of them, Bobby de la Paz, was assassinated while serving in Samar province.

It is not surprising that the rhetoric around primary health care became diluted with time, emphasizing health skills training with less mention of health as a political issue. Eventually, even these apolitical programs began to dwindle. In the Philippines, the Catholic Church, once so supportive of community-based health programs and primary health care, moved away back to "safe" charity missions.

By the 1990s, non-government organizations knew health for all by 2000 was a pipe dream. Now, in the 21st century, no one seems to even want to dream of new targets, willing to accept that health will never be accessible to the majority.