{"id":5525,"date":"2010-11-09T17:25:12","date_gmt":"2010-11-09T16:25:12","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=5525"},"modified":"2010-11-10T16:06:26","modified_gmt":"2010-11-10T15:06:26","slug":"daniel-palazuelos-grassroots-fertiliser","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2010\/11\/09\/daniel-palazuelos-grassroots-fertiliser\/","title":{"rendered":"Daniel Palazuelos: Grassroots fertiliser"},"content":{"rendered":"

\"DanielCommunity participation has had many forms.\u00a0One of the easiest to recognise is how communities have been involved in the provision of health care.\u00a0Examples run the spectrum from representation on hospital advisory boards to community activity at all levels, including the direct provision of care.[1]\u00a0\u00a0\u00a0\u00a0\u00a0<\/p>\n

<\/p>\n

Our work in Mesoamerica, therefore, has many other historical efforts from which we can learn.\u00a0One effort in particular illustrates important lessons: the Community Health Center (CHC) model of care that first took root in Boston at the Columbia Point public housing projects.\u00a0Designed by two physicians, H Jack Geiger and Count Gibson, the health center began as an experiment in a different model of care; \u201cthe hospital as we know it is an obsolete and ineffective institution for ambulatory care\u2026\u201d said Geiger in 1968.[2]\u00a0 They were bold indeed, but at the time so was the government. When they asked for a $25,000 grant from President Johnson, they instead received a million dollar grant from the Office of Economic Opportunity as part of the War of Poverty.\u00a0Years later it\u2019s clear that the investment paid off, as countless studies have demonstrated CHCs\u2019 significant contributions to the health of marginalised populations traditionally disenfranchised from the modern medical system.\u00a0But beyond merely moving the provision of care to a more accessible location, the CHC hoped to engage the communities in ways that got to the root of what it means to be a community.\u00a0 The grant application in 1965 read: \u201cThe need is not for the distribution of services to passive recipients, but for the active involvement of local populations in ways which will change their knowledge, attitudes, and motivation…\u201d Reading this now, over 40 years after it was written, this may seem benign, even a platitude. We should not, however, underestimate just how revolutionary this idea was. In short, the doctors said that a power shift needed to occur \u2013 a swing from the notion of doctor as all-powerful, to that of doctor as only one of many participants.\u00a0 If social determinants such as poverty and marginalisation were making people sick, then their health would need to come from a process of overall change, not just the application of an esoteric art by a great individual. Geiger continues: \u201cthey will emphasize the formation of community health associations and the training of local residents as community health assistants to stimulate change… Health associations [should be] capable of studying the community’s problems and negotiating with the administration of the health center in a meaningful way.\u201d\u00a0 Ultimately, this value would become institutionalised when CHCs were mandated to have 51% of their board be comprised of patients from the same health center in order to receive federal funding; you can be sure that made more then a few project leaders take notice.<\/p>\n

But what does it mean to negotiate in a \u201cmeaningful way\u201d with the administration?\u00a0 Who would decide what was meaningful?\u00a0As one might expect, doctors and administrators did not always ride these shifting tides easily. In many projects, the associations quickly recognised that their participation was often only advisory, and when the decision to take advice or ignore it lay with another group outside of their community, community participation quickly ran the risk of being diluted at best, or empty at worst.\u00a0This reminds me of the wry saying Cubans have about government mandated community participation: \u201cyes, we participate\u2026. but they decide.\u201d<\/p>\n

Perhaps the attendees at Alma Ata<\/a> kept the issue of community participation vague because they recognised that there were many different ways to implement it; keeping it imprecise would keep the door open for interpretation and, hopefully, innovation. David Werner, author of one of the most influential books ever written in Global Health, Where There Is No Doctor<\/em> (aka. Donde No Hay Doctor<\/em>), summed up two possibilities well.\u00a0 In his lecture entitled \u201cThe Village Health Worker \u2013 Lackey or Liberator,\u201d delivered in Tokyo, Japan just months before Alma Ata, he explained two different models of how communities can participate in health, as evident by how one interacts with another manifestation of community participation, the village health worker.\u00a0On one hand were the top-down approaches, where professionals and experts determine what poor communities need and then find ways to let community members contribute to these objectives as, in his words, \u201clackeys\u201d for someone else\u2019s goals.<\/p>\n

On the other hand were the bottom-up approaches, where through the process of a participatory Freirean approach to education, community members are taught to analyze their situation, consider possible solutions, and then lead initiatives that will \u201cliberate\u201d them from the clutches of disease and poverty.[3]\u00a0 This latter approach has often been termed the \u201cempowerment\u201d model.[4]\u00a0 While the term \u201cempowerment\u201d has of late become over-used, often being the must-have word in any Global Health application hoping to secure a grant, it goes without saying that this concept has been hard to incorporate in its purest form.\u00a0 By definition, one cannot \u201cempower\u201d someone else \u2013 empowerment, instead, is a dynamic process by which a person or group themselves gain increased ability to control the factors influencing their health.\u00a0 But what if this process threatens the status quo?\u00a0 It is always easier for those who currently benefit from business-as-usual to say that one should strive for equity and empowerment than to actually give up control of how resources might be used.<\/p>\n

The question remains: if participation is about transferring power, how much is enough? And if the powerful don\u2019t easily give up power easily, which is short hand for resources and the ability to decide how to use them, what is the true golden path to helping communities empower themselves?\u00a0<\/p>\n

——————————————————————————–<\/p>\n

[1] Maher D, Floyd K, Jaramillo E, Nkhoma W, Nyarko E, Wilkinson D, Raviglione M.\u00a0 Community Contribution to TB Care: Practice and Policy. Geneva: WHO; 2003.<\/a><\/p>\n

[2] Geiger HJ. The First Community Health Centers: A Model of Enduring Value.\u00a0 J Ambulatory Care Management. 2005; 28(4):313-320.<\/a><\/p>\n

\u00a0[3] The Freirean approach to education comes from Paolo Freire, perhaps one of the most influential philosophers about education in the 20th century.\u00a0 His most famous book, Pedagogy of the Oppressed<\/em>, explains the ways in which education can be used as either a tool of oppression or a tool for liberation.\u00a0 Without these ideas, Donde No Hay Doctor<\/em> would probably have never been written.<\/p>\n

[4] Laverack G. Improving Health Outcomes through Community Empowerment: A Review of the Literature. J Health Popul Nutr. Mar 2006; 24(1):113-120.<\/a><\/p>\n

Daniel Palazuelos<\/strong> is an associate physician at the Brigham and Women\u2019s Hospital, and an instructor of medicine at Harvard Medical School. He is the clinical director of the Partners In Health-supported projects in Chiapas, Mexico and Guatemala. Partners In Health is a US-based NGO working to bring advanced medical care to the world\u2019s sickest and poorest people. In this role, he lives for half of the year in isolated communities in the Sierra Madre Mountains, training local community health promoters, providing medical care, conducting research, hosting medical student projects, and creating original curricula. For the other half of the year, he lives in Boston and practices inpatient medicine with the hospitalist group at the Brigham.<\/em><\/p>\n

Competing interests: DP does pro-bono work for Partners for Health, a Boston-based NGO and they assist him with travel support to work abroad.<\/p>\n","protected":false},"excerpt":{"rendered":"

Community participation has had many forms.\u00a0One of the easiest to recognise is how communities have been involved in the provision of health care.\u00a0Examples run the spectrum from representation on hospital […]<\/p>\n

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