Don't get me wrong. I love the WHO, what it stands
for, and when I am sick, I want a medical doctor,
not some social scientist, to tell me how to
prevent illness. Certainly, there have been dramatic
improvements in disease prevention. Besides vaccines
and drugs, advances like pasteurisation of milk,
chlorination of water have saved the lives of
millions and helped raise life expectancy everywhere.
Smallpox has been eradicated and polio eradication
is around the corner. But despite the number
of diagnostics, drugs, and vaccines developed
during the 20th century, medical researchers
and practitioners continue to struggle against
not only familiar diseases but also an ever-growing
number of emerging infectious diseases such as
HIV and hepatitis C. Why is it that despite over
a century of efforts, we appear unable to sustain
a successful response against long-standing,
emerging, and re-emerging diseases?
In searching for reasons, one that surfaces
is that the dominance of germ theory locked
infectious diseases into biomedical theories
of causation. Thus, most medical experts have
had difficulty broadening their vision to incorporate
an examination of social and environmental
conditions that explain why a disease occurs
in the first place and how it could be prevented
effectively. Certainly, the evidence is incontrovertible:
exposure to contaminants released in the air,
water and soil may be the primary cause of
illnesses ranging from cancer and anaemia to
infertility, mental retardation, neurological,
gastrointestinal and endocrine disorders, asthma
and compromised immune systems that may in
turn interact with communicable diseases.
The major structural impediment
to the elimination of infectious diseases,
including water and
air-borne diseases, is poverty. Structural
inequalities, including where and how people
live, must be addressed, and the tools to do
so defy reductionism … it is about more
than bugs and drugs.
For me, in turning my attention to work with
social entrepreneurs, it was enormously refreshing
to discover that they are excellent health
promoters. Even if they began working in areas
that had nothing to do with disease or health,
the effects of their work have important health
repercussions. Conversely, I am fascinated
with the medical doctors who have recognized
the limitations of their ability to create
health, and have dramatically re-oriented the
way in which they live up to the Hippocratic
Oath.
An outstanding case in point is that of the
Indian medical doctors, Dr.Raj Arole and his
late wife, Dr. Mabelle Arole. Both had received
their training in the best medical institutions
in their country and in the USA and were committed
to provide health for the Indian poor. Upon
their return from the USA, they were invited
by a local political leader in Jamkhed, Maharashtra
state, to set up a hospital to take care of
obstetrics and other emergencies. When the
Aroles explained their intention of working
with the people to improve their health through
preventive programs, the leaders were not impressed.
However, having no other doctors willing to
work in this remote area of the state, they
emptied a dispensary in the middle of a cattle
market and provided a couple of sheds to start
the hospital. This was over thirty years ago,
in 1970.
Using curative services as
an entry point, the Aroles came into contact
with more and
more village people. It soon became evident
that poor people were not interested in health.
They were interested in relief from other pressing
needs, water, jobs and food. So, setting aside
their curative agenda, the Aroles began to
concentrate on the villagers' need for safe
drinking water. They identified an NGO involved
in drilling tube wells and mobilized funds
from a church mission to undertake this effort.
But the Dalits ("untouchables") were
concerned that they would not have access to
the water if the well were in the main village.
Similar to social entrepreneurs everywhere,
the Aroles sought a creative solution. They
used a traditional practice to solve the dilemma.
A water diviner was taken into confidence and
asked to walk through the whole village but
divine water mainly in the Dalit section. Over
150 tube wells were drilled in Dalit areas
of villages. The Aroles began to gain the confidence
of the most marginalized of the poor. But attaining
health improvements also required a change
in people's attitudes towards religious, political
and caste differences. The Aroles started organizing
volleyball games as a way of getting people
together and breaking down the barriers. Over
time, these games became the meeting place
for more serious discussions on village development
among all.
Can you imagine your average medical practitioner
bringing in a water diviner and organizing
volleyball games as a way of improving health?
In the mid 1970s, the Aroles stumbled upon
an innovation that transformed health delivery
and changed the lives of the surrounding villages
forever. They had grown increasingly frustrated
with the failure of auxiliary nurse midwives
(ANMs) to influence the health practices and
beliefs of the people in the villages to which
these women were assigned. The villages needed
someone who could really communicate with villagers.
The Aroles convinced community leaders that
their own women were better suited to reach
out to neighbors to improve their health conditions.
The village leaders reluctantly agreed and
nine women were initially identified to participate
in the training process. They came from different
castes and had never left their homes. Prejudices
ran deep among them, and at first they found
it difficult to even eat together. But soon
they discovered they had more in common than
differences.
Through this process with the first 9 women,
and gradually with more, the Aroles proved
that poor illiterate and in most cases, low
caste women can be more effective primary health
care providers than trained nurses or literate
men and women who do not understand the reality
of the villages in which they work. Today,
thousands of village women in over 300 villages
have learned how to address common water borne
illnesses such as diarrhoea and cholera. They
have learned how to immunize, how to provide
women with pre-natal care, support family members
in child delivery for low-risk births and post-partum
care, as well as provide guidance on nutrition
and other health information.
But what has happened in relation to illness
and death over the last 30 years in these 300
villages? The infant mortality rate has dropped
from 180/1,000 in 1971, to 19/1,000 in 1999
(compared to 72/1,000 in 1999 in India as a
whole); maternal mortality was reduced from
650/100,000 in 1971, to 174/100,000 in 1999,
(410/100,000 was the average in India in 1999);
rates of child immunization increased from
0.5% in 1970 to 99% in 1999, as compared to
78% coverage in India in the latter year. Malnourished
children dropped from 60% to 5% in that period
(today, 52% of Indian children are malnourished).
The Arole's efforts also achieved significant
declines in leprosy and TB prevalence rates.
They have stimulated and supported villages
in their provision of safe drinking water,
construction of dams and forestation programs.
Credit programs have been widely established
and major changes in the local political processes
have eroded control of the dominant elites
and given way to local democracy.
All of this has been about health and sustainable
development. To get there, it took thirty years
and two social entrepreneurs who, despite being
well-prepared medical professionals, divested
themselves of the power and privilege of the
medical profession and shared their knowledge
of health promotion with the poor. Neither
one ever wore a white robe or a stethoscope
around their necks, all symbols of the medical
establishment which distance doctors and nurses
from the people they serve. They risked breaking
out of the security of a profession that feels
most comfortable with illness and ventured
into the unknown territory of health.
(Note: Pamela Hartigan is Managing Director,
Schwab Foundation for Social Entrepreneurship
in Geneva.)
