GIVING CONTROL BACK TO THE PEOPLE
Costly medicines can actually increase ill health, while people's sense of control over their health care may still be the crucial factor in maintaining their well-being.
By David Werner
The health workers were eager. They demonstrated their baby-weighing scheme, complete with animated health talks. Then, sitting down under a giant fig tree with the mothers and children of the village, they boasted of the dramatic fall in child deaths and reduction in malnutrition over the past two years.
It happened since their community health programme began in Makipawa on the outskirts of Tyacloban City. Their regular health talks to the mothers on nutrition and hygiene were to be thanked, they suggested.
'Nonsense!' retorted the mothers. Nurses and health officers had been telling them how to feed and care for their children for years. 'If our children don't get much to eat,' said one mother angrily, 'it's because our pockets are empty - not our heads!'
'Do you earn more money now than you did two years ago?' we asked. No one had an answer.
We asked the mothers how much of their family's earning they usually spent on health care. It averaged between 10% and 12%: quite low compared to many poor families in Asia, Africa and Latin America, who spend up to half their earnings on health care.
'We used to spend a lot more,' explained a mother. The others agreed: before the programme started, they had often spent up to 40% or more of their earnings on medicine.
'Our little ones used to be so skinny, they were always getting sick. We'd go to the shaman, then the pharmacist, then the doctor. What the doctor prescribed sometimes cost us a month's wages!'
'But why do you spend less now?' we asked.
'Because we make a lot of our own medicines,' was the answer. Part of the community health programme involved families in collectively producing their own herbal medicines for treating common problems like colds, coughs, scabies, worms and diarrhoea. These are based on traditional home remedies. With an input from modern medical science, the local herbal treatment for diarrhoea, for instance, has become the basis for an oral rehydration therapy. And their cold remedy includes 'bitter orange' extract to provide Vitamin C.
'What we used to spend on medicines and doctors we can now spend on food. Our children are fatter so they don't get sick so often. That way we spend even less on medicines. And can feed them still better.'
'Do you realise what we are saying?' asked one older woman whose face reflected a lifetime of hardship. 'We are saying it was the doctors and their medicines that were killing our babies.'
'That's a bit extreme,' objected one of the health workers mildly. 'What you mean is the high cost of commercial and professionally controlled health care contributes to the hunger and poor health of your children.'
'It comes to the same thing!' muttered the woman. 'The wolves grow fat on our children's flesh.'
This account demonstrates how costly medicines can actually increase ill health. And it gives some indication of how people's confidence and understanding can be heightened when they have control over the things they need for survival. But even when the medicine is given out freely in government clinics, people's sense of control over their health care may still be the crucial factor in maintaining their well-being - as the next example demonstrates.
Diarrhoea is the biggest killer of children living in poverty. The children die not from the infection causing the diarrhoea, but because they lose too much water. Thid dehydration can usually be prevented (or corrected) if a child with diarrhoea is given lots of liquid. The best rehydration drink contains sugar or starch, a little salt and if possible a bit of potassium. The United Nations Children's Fund (UNICEF) estimates that deaths from diarrhoea could be halved if mothers learned how to rehydrate their children.
But the death rate from diarrhoea in the world's poorest communities is 200 times that in Sweden or Holland. Therefore oral rehydration therapy as the treatment is only a stop-gap measure. To eliminate diarrhoea as a major cause of death means correcting the underlying causes: poverty, malnutrition, unhealthy living conditions. This, in turn, requires major social changes that are only likely to come about through empowerment and mobilisation of the disadvantaged people whose children are dying.
This concern has triggered a heated debate about how to promote oral rehydration. Should it be done in ways that make people more self-reliant? Or in ways that increase their dependence on centralised services, supplies and authority? The controversy focuses on whether to use factory-produced packets of oral rehydration salts (ORS) or home-made rehydration mixes.
The commercially produced packets have been strongly promoted by UNICEF, the World Health Organisation and most governments. Millions have been spent setting up ORS factories in poor countries and the packets are usually distributed through health centres.
Home-mix ORS, which can be made by adding a handful of sugar and a pinch of salt to a glass of clean water, has been shown to be just as effective as ORS packets. More effective still are cereal-based home mixes, made with rice, maize, millet or whatever basic grain is in the house. Home mixes are cheaper, can be adapted to local traditions and allow mothers to begin treatment as soon as the child falls ill.
When people discover they have control over some aspects of their well-being, they gain confidence to work collectively for more fundamental changes. Thus a simple technology like oral rehydration can become a real stepping stone toward a healthier society. - Third World Network Features
About the writer: David Werner, of the California-based Hesperian Foundation, is the author of many demystifying health books for developing countries, including the best-selling Where There is No Doctor.
The above article first appeared in Link (Vol. 16, No. 3, June 1998), the bulletin of the Asian Community Health Action Network.