• TABLE OF CONTENTS
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 Copyright
 Title Page
 Introduction
 How the project began
 The hospital
 Health promoters
 Extension services - public...
 Extension services - agriculture...
 The financing of the project
 The reproducibility of the...
 Guidelines for the public health...














Title: The Chimaltenango developement project in Guatemala
CITATION PAGE IMAGE ZOOMABLE
Full Citation
STANDARD VIEW MARC VIEW
Permanent Link: http://ufdc.ufl.edu/UF00072193/00001
 Material Information
Title: The Chimaltenango developement project in Guatemala
Physical Description: 21 leaves : ; 28 cm.
Language: English
Creator: Behrhorst, Carroll, 1922-
Mach, E. P
Instituto de Ciencia y Tecnologâia Agrâicolas (Guatemala)
Publisher: Instituto de Ciencia y Tecnologâia Agrâicolas
Place of Publication: Guatemala C.A
Publication Date: 1975
 Subjects
Subject: Public health -- Guatemala -- Chimaltenango (Dept.)   ( lcsh )
Cakchikel Indians -- Health and hygiene -- Guatemala -- Chimaltenango (Dept.)   ( lcsh )
Agriculture -- Economic aspects -- Guatemala -- Chimaltenango (Dept.)   ( lcsh )
Social conditions -- Chimaltenango (Guatemala : Dept.)   ( lcsh )
Genre: non-fiction   ( marcgt )
Spatial Coverage: Guatemala -- Chimaltenango
 Notes
Statement of Responsibility: Carroll Behrhorst ; in collaboration with E.P. Mach.
General Note: Cover title.
General Note: "... published in Health by the People, World Health Organization, Geneva, April 1975."
 Record Information
Bibliographic ID: UF00072193
Volume ID: VID00001
Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
Resource Identifier: oclc - 76803117

Table of Contents
    Copyright
        Copyright
    Title Page
        Title Page
    Introduction
        Page 1
        Page 2
    How the project began
        Page 3
        Page 4
    The hospital
        Page 5
    Health promoters
        Page 6
        Page 7
        Page 8
        Page 9
        Page 10
        Page 11
        Page 12
    Extension services - public health
        Page 13
        Page 14
    Extension services - agriculture and economics
        Page 15
    The financing of the project
        Page 16
        Page 17
    The reproducibility of the program
        Page 18
    Guidelines for the public health of the rural poor
        Page 18
        Page 19
        Page 20
        Page 21
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*THE CHIMALTENANGO DEVELOPMENT PROJECT

IN GUATEMALA











Carroll Behrhorst, M.D.
In collaboration with E.P. Mach, M.D..
Division of Strengthening of Health
Services, World Health Organization,
and published in HEALTH BY THE PEOPLE,
World Health Organization, Geneva,
April 1975







THE C1IMALTENANGO DEVELOPMENT
PROJECT IN GUATEMALA

CARROLL BEHRHORST, M.D.

In collaboration with E.P. Hac;.
Division of Strengthening of
Health Services, World Health
Organization, Geneva, Switzerlai-"


For 12 years we have lived and worked with the Cakchiquel Indians of
Guatemala, a proud, dignified, life-loving but impoverished/people whose
cultural heritage stems from the great Mayan civilization, which lavished_
its artistic and architectural riches through Central America and the
Yucatan Peninsula of Mexico in the centuries before the Spanish conquest
450 years ago.

We have gone to school with the Cakchiquels, letting them teach us
(myself a North American doctor trained in the complex technology of
modern medicine and companions) the simplicities of what the Cakchiquols
believe they need to live and prosper in he highlands of Guatemala, where
3,000,000 agrarian Indians eke out a bare existence beneath the slumbering
volcanoes that dominate this land of majestic beauty and sordid poverty,,

We have learned more from.our Indian friends than they have learned
from us and we have come to believe that much of what we have absorbed
here has wide application to the rural poc- throughout the world. Cer-
tainly, what we saw and heard on a survey of mission hospitals in Africa
and Asia in 1972 (for the United Presbyterian Church in the USA) confirmed
our suspicion that the problems and indicated solutions in Guatemala were
duplicated widely elsewhere. Despite differences of culture, language.
and race the rural poor of all continents share a common bond forged o!
poverty, exploitation, disease, malnutrition, and land hunger, As a resul'
of our "student days" with the Cakchiquels and our recent travels amon
peoples facing a similar battery of problems, we have reached a number of
conclusions concerning the great public health question of the day how
to break the back of disease among the almost 2,OGC million rural poor ::I
the less developed regions of the world. ,

The old answer was a simple/one: "We will eradicate disease by curir;
the sick". It was also a deceptive answer that brought balm to the spiit'_
of millions of donors in the industrialized countries while wasting hundr--.::i
of millions of dollars and untold/mental energy. No sooner was the patient ,
cured than he returned to a slough of poverty that onpe again felled him ,
within months, often within days, of his treatment.. .Curing the ailing .
from clinics and hospitals located in jungles, savannas, and mountains was,
something like trying to empty the Atlantic Ocean with a teaspoon. It
made the toiler feel active and useful and caused everyone to exclaim:
"My, what a beautifull teaspoon "'
\ ..
\ (*k
















Today our answer is at once more tentative and far more complex.
Before health can supplant disease among the 2,000 million rural poor of
the world, we believe that the following p:-oblems must be tackled aggres-
sively. Our listing os priorities generally reflects the opinions and feeling
of the people we serve:

1. Social and economic injustice
2. Land tenure
3. Agricultural production and marketing
4. Population control
5. Malnutrition
p '6. Health training
S 7. Curative medicine.

You will note that we list curative medicine as our last priority.
Twelve years ago, when we arrived in Guatemala from a medical practice
in Kansas, USA, we would have listed curing first. We learned the hard
way by personal experience. Our list may look formidable to you, so
formidable that a beginning by a single individual or group would seem
to bet ~; om from the start. Yet, impossible as the task may seem, we
are convinced that a fruitful beginning can be made by individuals outside
the health bureaucracies of the world. We are also convinced that with
careful nurturing and persistence an impact for wider change can be made
from the most humble and inexpensive start,. We think e \have proved it
in Guatemala although we have a long, long way to go yet. Let us
describe the origin and evolution of ourexperinent in the Indian highlands.,) i

S These highlands of Guatemala are like many areas of the non-socialist c''
/Third World as seen through the lens of economic and public health
Statistics. They are predominantly agricultural and poor in resouroeeS_
and the wealth that does exist is concentrated in the hands of an-elite class,
SThe gross national product is increasing,/largely through farm exports, but
S the great mass of the people do not share in these benefits. The condition 'i
Sof the Cakchiquels, oppressed and exploited by the Spanish conquistadores
-and-by more than 20 generations of their descendents, A/s reflected in the /
state of.public health. The infant mortality rate is one of the highest in
the world.-Respiratory infections, malnutrition, and intestinal disorders are
primary causes of 'd ath/and many of the other./diseases, such as measles,
tuberculosis, whooping cough, and influena no longer considered-threats
in the industrialized count es, still 'stalk the (idges /iandremote-valleys of
the Guatemalan highlands.- This is one of-the fe areas in Latin America
where the pre-Columbian population (called "Indian") is predominant. This
indigenous people, descendants of the ancient Maya, make up more than three-
fourths of the inhabitants of the highlands, They have held tenaciously to
their culture with a high degree of success, This demands that work with
them be done on their own terms, for they have little appetite to copy
modern cultures.


- 2 -








-3-


How the project began

When we first came to Chimaltenango, the hub of the Indian high-
lands, in 1962, we did little but walk around town, get acquainted with the
people, and play with the children. Gradually we were invited into their
homes to have coffee with them or sit down to a meal of tortilla and beans.
This went on for 3 months until we were .rell known and accepted in the
town and until we felt confident that we could fulfill a need. Then we
rented a building for $25 a month and opened a clinic. The first day
125 patients came, and we have never had less than that number since (the
average now is 200 a day). We were in the business of curing,

It did not take us long to realize that we were trying to empty, if not
the Atlantic Ocean, at least a good-sized lake, with a medical teaspoon. We
began to see the same patients returning after a few months with the same
ailments and we began to wonder what we should do about it. While this is
not the place to analyze our personal transformation, the basic change in
our thinking and attitudes can be symbolized by what happened to Jorge.

We met Jorge about a year after coming to Chimaltenango. He was a
handsome 5-year-old Indian boy, but he was suffering that day he came to
the clinic with his mother. He had puffy eyes, swollen feet, pigmentation
blemishes on his arms and legs, and stains the color of port wine. Quest-
ioning Jorge and his mother, we found that he lived in the village of San
Jacinto in the rugged mountain country near Chimaltenango. Since he was not
the first child from San Jacinto to come in with this problem, we decided to
go to the town and have a look at conditions there.

Several days later, with two nurses from the clinic, we drove to 3an
Jacinto by jeep. Although the village is only 8 km from Chimaltenango, the
journey was a long one. There was no road then and our jeep often became
mired in mud holes. At last we left the vehicle and walked the rest of the
way. The trouble in San Jacinto was not hard to daignose. Almost every
child we saw was malnourished and diarrhea was common in both adults and
childrend A great deal of coughing could be heard. As we visited the thatch-
roofed huts, we learned that the common diet had very little protein. The
village existed almost exclusively on tortillas and vegetables.

Why?' The people had no land to farm, only miserable little plots in
areas where the soil was poor, San Jacinto was almost completely surrounded
by large plantations operated for the benefit of absentee owners. The poor
of the village, seeking an opportunity to earn a bare living, customarily
packed up once a year and went to work on the big coffee fincas on the Pacific
Coast of Guatemala. Going from the cool highlands to the hot lowlands, they
fell victim to a variety of tropical ailments and often returned to their
village with tuberculosis. In fact,.whenr the two Indian nurses from our
clinic made a house-to-house survey a few weeks after our visit, they found
that'of 450 people, 105 had active tuberculosis.

We realized that no matter how many times we treated Jorge and other
youngsters from San Jacinto they would never be healthy until drastic changes










were made in the village. We began in a small, tentative way. A Peace Corps
volunteer attached to the clinic, Wayne Haage, made weekly visits to San
Jacinto, gained the confidence of the men, and began to teach better farming
methods to a group who tilled their small plots for survival. Later, our first
chicken project was started in the Village. We lent money from our initial
operating funds to 25 families tC raise chickens and produce eggs. Soon the
people began to eat more protein ,'an egg a day" became the slogan with some
families. The loan was repaid in full the borrowers giving us a portion of
the egg production in lieu of cashhi

Gradually our program expanded in San Jacinto. One of our kkchiquel
health promoterss", trained by us in Chimaltenango, opened his own little
clinic in the village and began treating the common ailments on a fee-for-
service basis At the villagers' request, our Indian extension workers from
the Chimaltenango program taught nutrition, health care, and farming methods.
Ten families banded together and bought some land from one big absentee owner,
using a small fund borrowed from us and paying us back conscientiously as crops
began to bring a dribble of cash to the town. Now San Jacinto plans a major
land-buying program, to be carried out when we have accumulated the necessary
land-loan revolving.fund, which has as its source grants from various inter-
national foundations. The women of the village have organized a weaving club
that brought in $3513 in the year 1973, a remarkable income when contrasted
with the pitiful handful of coins that people earned a decade ago.

Today San Jacinto is a reasonably healthy, economically viable community.
Malnutrition has all but disappeared and the dreaded tuberculosis has been
eliminated. You can walk through the village today without hearing a single
cough. Jorge himself is a robust teenager doing a man's work. While San Ja-
cinto is still poor, it has a new vibrancy compounded of protein, cash, and hope.
And that hope is no mirage. We are convinced that when the new revolving fund
becomes available, more men of San Jacinto will become proud land-owners and
that the little mountain town, once a scrap-heap of disease and apathy, will
become a prosperous agricultural community. A Cakchiquel family can flourish
on a few acres of its own land.

True, San JacintA is not the world, but a million San Jacintos might
transform the world. As our own program has evolved over the years, we can
see dozens of San Jacintos scattered through the Guatemalan highlands and
feel we are on the right track. In brief, what started as curing the sick
has broadened into a general community development program geared to the
services that the people want and need and focused always on that ultimate
goal acquisition of farm land by the Indians. But despite the change in
emphasis, we have never neglected curative medicine. Indeed, without curing,
our expanded program would have been most difficult, probably even impossible,
to achieve.

Our experience has hammered home an important truth on the tactics of
developing similar programs in impoverished areas. The man who does not plan
ways of doing himself out of a job is not doing the job. Institutionalized
charity from outside accomplishes little but the cosseting of the egos of
the helpers. If the program does not take root in native soil and native








- 5 -


hands, it will wither the moment the foreign helper ceases his aid. The
Cakchiquels receive no charity from us. They borrow at reasonable interest
rates from us, they pay for the services they want, and they increasingly
select the people they want to deliver those services. All of our health
promoters are Indians, as are most of our nurses and extension workers. We
shall consider our job completed the day a trained Cakchiquel doctor takes
over our medical and administrative chores at the Chimaltenango clinic,
hospital, and extension service.

Although the Indians in the Guatemalan highlands generally had accepted
modern medicine because of the wide availability of drugs in pharmacies, they
were nevertheless somewhat reluctant to accept our newly introduced service
because of the cultural barrier. Gradually, however, we were able to identify
with them and our serviceswere readily accepted.

It was not difficult at this point for us to offer treatment on terms
the local person could afford. Our work was being subsidized by the Lutheran
Church and we had access to a good deal of free and discount medicines. But,
obviously, if this arrangement were to continue indefinitely, the local
people would continue to depend on outside aid that was not entirely reliable.
Also it became apparent that other ways to cut costs and adjust conventional
medical approaches were needed if more people were to be reached.

The hospital
Some illnesses needing prolonged treatment are best attended while the
patient is in hospital, particularly if he lives at a great distance and is
not able to travel back and forth daily. Conventional hospitals, however,
are a very expensive proposition, poor rural areas cannot afford the hotel
services and elaborate facilities of modern hospitals. In fact, impressive
buildings with sophisticated rules of procedure are almost certain.to alien-
ate the local people.

In Chimaltenango we decided to build a very modest hospital where the
patient could stay with his or her family, who would be responsible for pre-
paring food and providing basic patient care. This arrangement turned out
to be not only far less expensive but also far more humane. If you visit
our hospital today, you will find scores of patients attended by members of
their own families; this eliminates the need for the complex hotel services
that make the sophisticated hospital so costly to the patient.

Costs to the patient for all our hospital services, including medicine,
work out at the equivalent of $0.75 per day. This payment does not quite
cover all expenses, but that is because our hospital must function as a public
hospital since it is the only hospital in the Department of Chimaltenango,
which has more than 200,000 inhabitants. We must accept any and all patients
(we would anyway) regardless of their ability to pay even the most modest
charge. Also, we offer such ancillary services as ambulance and transport
and this cuts into our budget.







-6-

Health promoters -L

we had to challenge some of the sacred institutions of modern medicine
in orde: to meet the needs of the people on their own terms. Once we had re-
formulated the concept of "hospital", we went on to challenge "the doctor" /
himself. This is much more delicate ground. In/most developed countries -
people still believe that only a medical doctor/with a degree acquired ter tu
long academic training is competent to cure even minor ailments. This is -/
simply not true. Even in the industrialized countriesjthe vast majority of
patients are in no real need of a sophisticated doctor. The developed
countries can ill afford to perpetuate the myth of the 'ndisp nsable-doctor
-. poor areas, such as rural Guatemala, plainly cannot fford/the/nyth at all,

After the first couple of years of seeing 125-150 patients a day we began
to realize that a bright Cakchiquel, given a certain amount of inexpensive
training, could t:eat the most common afflictions just as well as a university-
trained doctor. Not only would the investment in the education of this ':health
prorztor:: be far more modest in both time and finances, but the fact that the
local health promoter could respond to the customs of his own people -ould be
invaluable in terms of public health, the acceptability of modern medicine, and
the development of other needed community services.

It should be emphasized that the concept of using community health promo-
tors came about not only because of a vacuum of medical help and lack of medical
professionals but also because it was genuinely felt that the work of a local
community-rooted and community-oriented worker would be more readily accepted,
and, in fact, the total task did not demand the very costly services of a tech..
nically trained physician.

The doctor/population ratio in rural Guatemala is variously stated. but the
statistics need not be quoted since in most communities a professional medical
servLic simply does not exist. Now the government has an energetic program of
introducing medical students to rural areas. This may be a step in the right
direction but its contribution towards meeting the total medical need is minimal,
nd in vti of the current rapid population growth an even more vigorous program
would still fail to keep up with the expanding need.

So, in order to help meet the urgent needs in many medically neglected
cormnities, wae began to train responsible Indians from those communities how
to recognize and alleviate common medical problems. This program now comprises
more than 70 health promoters from 50 communities, not including some individuals
we have trained in intensive courses. The common problems here are quite simple,
diarrhea and pneumonia accounting for more than 75% of the patient visits to our
clinic and hospital. Our trainees, or promoterss" as we call them, come from
most areas of the Departmentsof .Chimaltenango, Solol&, Sacatepequez, and Quiche.
Their forinal education ended, on the average, after the third grade of elementary
school, but they are for the most part bright, eager to learn, and quite skilfull
at treating ailments within their competence. One day we took an American
specialist in tropical medicine on a tour of some of the health promoters at
work. Hs- was skeptical that men with so little formal education could dispense









-7-


adequate ,-dical care; but as the day wore on and he found the promoters dealing
knowlz';,- -.ly with one ailment after another, his skepticism wilted. Finally,
he thought he had caught one of the promoters giving incorrect treatment. "You
have the right disease, but the wrong remedy", he said to the promoter. "The
specific idicatoed here is penicillin". The Indian promoter shook his head.
"Ah", he replied, "but this patient is allergic to penicillin."

VW have found that it is of vital importance to select the trainees with
care, At first we generally accepted those who were recommended to us by a
local priest or a Peace Corps volunteer. We have since learned better. Our
approach now is to encourage each community to set up a community betterment
committee, which includes a health committee. Then the community health commit-
tee selects the person whom we are to train. This works well and avoids some
of the pitfalls characteristic of the medical monopoly in the developed count-
ries. The man we train represents his community and the community is respon-
sible for him and can discipline him, retain him, or recommend his dismissal.
We had to withdraw- one health promoter because his local health committee was
unhappy v-ri-h thhe way he was offering his services,

The local committee has a list of the prices of medicines. Each promoter
is expected to charge according to this price list. In addition, he can charge
a fee of 25 cents for his call or for his services. Since the community is in-
volved in setting the charges, it is less likely that a monopoly can develop
such as thb:t in the USA and other countries where the physician can generally
charge -whatcTer he likes. Since we wanted to avoid such a monopoly, we insisted
that a community requiring a community health leader must first form a committee
to be responsible for he promoter, both during his training and later.

Most promoters come once a week for either Tuesday or Friday sessions and
spend the entire day with us. The day begins with hospital rounds to check
patients w-ith a doctor or the supervisor. The student sees the patient and his
problem and learns how that problem could be handled in his home village and how
it could be prevented in the future. We usually do not speak of diseases as
such, but rather -talk of the patients symptoms, since symptoms have meaning
whils diseose- do not.

W.e choiulcd l ke to emphasize our belief that any program for training lay
medical w%_rkers that does not include facilities for patient demonstration
cannot be eficctivc, Seeing a patient with an ailment is of more value than
6 hou-s of lectures. Films, books, pamphlets, and seminars all have their place,
along with clasroom lectures, but hey are adjuncts to a living demonstration,
not substitutes for it.

We are frequently asked how the local medical profession and the govern-
ment look upon our program, since it obviously contradicts the idea cherished
by the profession that only a physician can treat a patient. The answer is that
they all tolerate the program because of the scarcity of professional help in
the deprived communities, or, as a visitor who is very interested in training
lay medical workers recently told us: "The answer is simple. It works." Just
now we are beginning to coordinate our entire medical program within the struct-








- 8 '


ure of the local health department so that there will be no overlapping of ser-
vices and we can present a united front Included in the plan is a proposal
to use our promoters as agents of various health and preventive programs spon-
sored by the Department of Public Health, we have long been aiming towards
this integration because we earnestly believe that any program developed and
evolved by a foreigner is of no permanent value unless it is eventually accepted,
supported, and understood by the local government or other local agencies. We
should never create anything that cannot be locally self-sustaining.

Our program of health promoter training is a continuous one. Promoters
are usually trained in groups, attending sessions once weekly for a year. A
promoter may enter at any time. Nearly all of them, even those who began their
training more than 8 years ago, still come every week to learn new techniques
and treatments. A promoter must attend sessions for a minimum of a year before
he is allowed to dispense medicines and give injections. We give at least
monthly examinations in which each promoter must describe what he sees in a
patient, what is to be done for the ailment, and what'might be done in the
patient's home to prevent a recurrence of the problem. Generally the promoters
do quite well. On the last examination, given just before this was written,
all gave better than acceptable answers, the majority being excellent. The
promoters are visited regularly on the job by a supervisor, who consults and
advises. The supervisor is one of the older promoters, an Indian who is in
complete charge of the program. He consults the doctor, or another profes-
sional, only when, in his opinion, the problem warrants it.

The Indian supervisor, Carlos Xoquic, is in complete charge. of the continued
training, supervision, and management of the community health promoter program.
What initially may have been a "one-man show", conceived and nurtured by an ex-
patriate, is now completely in the hands of the local people, supervised by
Carlos in his communal-type relationship with the other promoters. Promotors
are encouraged to keep records on all patients 'and these records are checked by
the field supervisor.

It should be noted that prior to the development of this health promoter
program in the Chimaltenango area there was not a complete vacuum of medical
services. Modern medicine was empirically dispensed by a pharmacist, along
with that of the curanderos (Indian curers), who delivered a mixture of trad-
itional and modern therapy.

As noted earlier, modern medicines were generally available in pharmacies
and, as in many places in the world, are still valuable for common ailments.
Curanderss were generally few in number in our section of the Guatemalan high-
lands because of this acceptance of modern medicine. Two of the curanderos
elected to upgrade their service in a sense and become promoters in our program.
One other local curandero who is well accepted by his community openly collab-
orates with us, referring unusual problems to our clinic, and we in turn send
patients to him who need further follow-up and injections.

Since the promoters generally work with poverty-stricken people who often
cannot at the moment offer to pay cash, a system of credit that is both effective









-9-


and reliable has been developed by the promoters. The success of this system
is the result of the culture of the highland Indian, where responsibility,
respect, and honesty are all part of local tradition,

Although the health promoters were trained over a period of a year (coming
one day per week) and were not allowed to undertake medical work during that
time, they did engage in other community service work; they are trained in
total community service and they were actively involved in work of this kind
during their medical training period.

All medicine in the health promoter program is bought locally in Guatemala
City from drug manufacturers. The buying and selling of medicines is strictly
business. Our clinic places the orders for the medicines, since we can buy at
reduced hospital prices. All supplies are then passed on to the promoters'
medicine cooperative at our price plus a 10% handling fee. The promoters have
a three-man committee to regulate the buying and selling, one of the three being
responsible for the mechanics of the sales. The medicine cooperative then sells
directly to the promoters at the cooperative's purchase price, plus 5% for its
expenses. Thus, medicine is available at reduced prices, much below those
quoted in the pharmacies. This plan might not work in some countries where
medicines are not available locally at reasonable prices.

Our promoters can buy only those medicines that we believe they can dispense
with minimum risk to the patient. Any drug with potentially serious side effects
cannot be bought or used. Adrenal corticosteroids and digitalis preparations,
for instance, may not be included in the promoter's medicine chest.

We teach the promoter not only what he can do but also what he must not do.
For example, an elderly man with swollen feet and shortness of breath probably
has heart failure and the promoter must see that the man receives professional
help, even if it means carrying him out of a village in a chair tied to a port-
er's back. The promoters are trained to identify and treat the majority of
diseases in their villages. However, they all know the limits of their capa-
city and they refer difficult cases to the clinic in Chimaltenango or to another
nearby health center. One study of the effectiveness of our promoters showed
a low percentage of error in treatment, about 95,. The study was made by the
University of Kentucky's department of community medicine some 7 years ago.
We are now planning a more elaborate survey to determine the exact quality of
work of each promoter.

One point concerning the delivery of "care" to a patient is not generally
understood, particularly by professionals. Since medical service generally is
provided for those in need, it is thought that the patient should accept it
gratefully, even if the service is not on his terms but on those of the provider.
But medicine should be practiced for the benefit of the patient, in a manner
understood and acceptable to him, and with the patient participating in the
decision-making on what is to happen to his health and his life. "Care" should
be so dedicated and so delivered that the patient can help decide his own medical
destiny. This, of course, has not been the case in most medical delivery systems.









- 10 -


Recently a medical man, after visiting one of our health promoters, asked
why the promoter did not send his Indian patients to the local health center
since, said the doctor, the goal of any medical program should be to bring pro-
fessional care to the people. The fact that this health center was staffed by
non-Indians did not seem relevant to him. We replied that the promoters do
collaborate with health centers where they exist, but it is for the patient
himself to decide where he wants to be treated. The same doctor, after spending
a week training himself in the total program and visiting first-hand the work of
the various promoters, came to understand why patients prefer treatment by the
promoters to attending the health center, and agreed with us that we should
accept the patient's decision as to which type of treatment he should receive.
In addition, he did not think it necessary to send the patients to the referral
center, since they were well cared for by the promoter.

in the highlands of Guatemala, large numbers of Indians prefer to be treat-
ed by their own kind, regardless of the degree of skilled training, rather than
be attended by a non-Indian medical professional. This being the case, we honor
the patient's wish to be served by whomever he wants and we, therefore, train
the type of person the patient trusts and accepts. If this stings the pride
and conceit of members of the doctors' guild, so be it. The monopoly of doctors
has for centuries dictated to the patient what service he will receive. The
fact that this system is traditional in the profession in no way makes it just,
serviceable, or humane. Medicine needs a new watershed, a new tradition whereby
technicians and professionals, together with the community, consider the people's
needs and where they wish to go when they are sick. It is a tragic error to
assume that the whole wide world is content to be treated (or mistreated) by
highly schooled technocrats rather than by an unsophisticated person.

The following is an example of the local Indian people's preference for
care from those of their own culture. In a large nearby Indian town, three
types of medical services are available a health center staffed by non-Indian
nurses and medical students, a local curandero, and two community health pro-
motors. If local people are asked where they prefer to go when they are sick,
the great majority say they prefer to be attended by either the curandero or the
health promoters, In fact, a past mayor of the town said that he believed only
about 5% of the population prefer to go to the professionally staffed health
center, the remaining 95% preferring the non-professionals.

The reason why non-professionals are preferred to professionals is primar-
ily cultural; there is suspicion of those from outside the community's own
group, particularly those whose technical training is identified with the non-
Indian culture.

We are now contemplating a broad study of a large number of communities in
Guatemala, to learn where people wish to go when they are sick. It can then be
determined which type of health care delivery system best fits the patients'
needs and demands, If the majority feel thay are best "cared for" by a health
promoter or empiric of their own culture rather than by professionals of another
culture, then those involved with health planning are wasting their time and








-11-


valuable resources by demanding that only the highly schooled should offer
services. If the majority prefer care by health promoters, then it will be
reasonable to upgrade the unsophisticated and cease to emphasize the sophisti-
cated. Our guess is that this is true in many areas of the world, regardless
of cultural variations. What is neede- is to determine what the patient really
wants and then take him as an equal partner in the decision-making as to his
care and cure,

In addition to the curing aspects of their labors, the health promotors
have an impact on public health and nutrition. Our promoters are community
catalysts. They work in many spheres other lhan curative medicine. Vaccina-
tions, tuberculosis control and treatment, literacy programs, family planning,
the organization of men's and women's clubs, agricultural extension, the intro-
duction of fertilizers, new crops and better seeds, chicken projects, improv-
ing animal husbandry all are part of the promoters' work and responsibility.

It may be asked how a promoter can find the time and the talent to be
such a community catalyst and be engaged in such a wide variety of community
activities, During the training period which, as mentioned earlier, is con-
tinuous, with the promoters trained more than 8 years ago still attending reg-
ularly, they are taught expertise in total community concern and involvement.
Not only d-es our medical staff in Chimaltenango participate in the training
of the promoters but also the program's Indian agronomist, family planning
workers, visiting government experts, and Peace Corps volunteers add to this
diversified training with demonstrations, field visits, and formal classes.
Less than half of the time ef the training schedule is spent on curative medi-
cine, the remainder being devoted to instruction in total community service.

It may be asked why the promoters are willing to spend so much of their
time in non-profit making work such as their other community service. Besides
the profit motive that is involved in their curative work, there is a real
dedication to being useful to others in the community, which involves working
7 days a week. This can be explained partly by the nature of the value system
of the Guatemalan Indian. Generally, Indians hold respect, dignity, and honesty
in high regard. In such a situation self-respect is quite natural and from it
there easily follows respect for others and the ability to be genuinely con-
cerned for others in the community. No doubt the prestige gained by being a
community leader and community server is also important in motivating these
workers to give up so much mf their time on behalf of the community.

The best supervision is continued education and training. Supervision
includes regular attendance at training sessions, a written and oral examination
once monthly, the submission of monthly reports on patients treated and review
of their medical records, and field visits by the supervisor to the promoter's
treatment center. If the promoter does not maintain acceptable standards of
care and treatment, the medicine cooperative may refuse to sell him medicine.

The profit motive naturally plays a part in the promoters' attitudes
towards their jobs. The Cakchiquels are skilled traders with an acute business
sense, and the idea of a "medical business" dovetails nicely with their concepts.








-12-


Although it is not encouraged, some promoters make their entire livelihood
from their medical practice. Others use it as a supplement. Some have ad-
vanced to the point of owning motorcycles so they can reach distant areas more
easily. Without exception, every promoter is more secure financially than he
was before training; at the same time he renders a service never before per-
formed in his village. Moreover, no promoter receives any pay from the parent
organization in Chimaltenango.

The total program comprises an intensive medical and agricultural exten-
sion service that includes Indian agronomists and nurses (those nurses are not
graduates but locally trained in our facilities), who make a considerable con-
tribution to the community health promoter program, wDrking side by side with
the promoters and sharing their experience and expertise. For example, when
making their field visits, the agronomists and nurses spend time with the
local promoter, counselling him and giving other on-the-spot help-

Each of our promoters treats an average of over 1,000 patients in a year.
The outside cost of the service has been negligible. The expenses involved
in training, continue! education and supervision are the salary of the one
Indian supervisor ($100 a month), the salary of a Peace Corps volunteer, the
time given by the doctor, and a very small amount for training materials,
While in training the promoters pay their own expenses. We paid for their
bus travel early in the program but have since discontinued this arrangement.
All the remaining funds come from the people in the communities being served
on a fee basis. The total outside cost of maintaining the program for 70
promoters is far less than the cost of training one sophisticated doctor. We
estimate our overhead costs at about $70 a year per promoter, as compared to
the $7,500 $20,000 required annually to sustain a professional doctor.

We can see no reasons, other than the objections of monopoly and special
interest concerns, why a system similar to ours could not be initiated in the
developed countries, including the USA. The professional journals and the mass
media in general provide ample data on the lack of medical curing by the pro-
fessionals and on the need for more medical students and more medical schools
and classes, for the use of computer analysis, for orientation to rural and
slum areas, for emphasis on community medicine, and for obligatory service in
deprived areas by medical students and recent graduates. However, these are
only balm for the problem. Radical surgery, not sticking plaster, is needed
on the medical care delivery system. The entire professional system needs re-
structuring so that general medical knowledge and simple medical tools are
made available to the hundreds of millions of people with the ability to cure
themselves. Lest we doctors forget, nature cures most ailments, sometimes in
spite of the physician. The majority of medical problems are self-limited
and run their natural course. The physician and the profession have usually
taken credit for nature's work and have given the impression that the doctor
of medicine is responsible for health. However, examiniti.an of the causes and
natural course of disease reveals that this is a misconception and that the
doctor has little to do with the overall health of the population. Many in
the profession still cling to the notion that they are curative deities; they
have denied, or failed to understand, their stark limitations as real healers.







-13-

This has led the doctor to be miserly with his information and force d the
patient to come to the monopoly for any and all ailments. However, we suspect
that this deception and the associated monopolization of medical practice may
sound come to an end. We think that during the next half-century medicine will
cross the greatest watershed in its history. The doctor of the future will
cease to be just a curerr", and will enter his rightful place as a real healer
who teaches his patients to care for themselves and to come to him only when
the situation is such that nature itself cannot cure, and expert sophisticated
help is needed.

Extension services public health

Except for the training of promoters, our medical extension program has
not developed as we should like, chiefly because of a shortage of time, funds
and trained personnel. Nevertheless, we have moved into this area with con-
siderable energy. Extension work has included the training of intelligent
Indian women; Snown as extension workers, who travel to various villages to-
work with families and groups to encourage and demonstrate many aspects of
community health. This program consists of such activities as nutrition and
hygiene classes, sewing classes, home demonstrations,, home gardens, and chicken
projects.

The following short narrative illustrates the work of our extension pro-
gram. Maria, one of our extension nurses, is working with the women in La Bola
de Oro, a village abysmally deprived, with malnutrition, low agricultural
production, unjust land tenure, lost hope, and general deprivation as intoler-
able as can be imagined. When a group of villagers was organized, they ex-
pressed interest in activities such as cooking classes, family gardening,
obtaining cleaner water, and learning to read a little, But high on their
list of priorities was learning to embroider, something unknown to the women
even though the finest hand-loom weaving had been done in the village for
centuries. Nutrition classes were acceptable, but the women really wanted to
embroider, so Maria is teaching them to embroider. Many might say that this
is a waste of time and energy, and poor stewardship of funds. Maria says that
while the embroidering is going on she enters into various dialogues with the
women to get them to consider their other needs carefully. Then the decisions
and requests will come from them, will have roots, and will eventually bring
meaningful action and results.

Action and results have actually already been achieved to a significant
degree in that the women have started a chicken project and a program of weav-
ing to earn money, garden projects are in operation, and their husbands have
also become involved in organizing pig and goat projects and forming a cooper-
ative group to buy a piece of land,

This story illustrates that what may at first sight seem a useless act-
ivity with the people can lead to meaningful action if properly dedicated and
oriented.







- 14 -


Since these extersionists are Indian women, speak the Cakchiquel language,
wear the native garb, and are identified as Indians, they have been a potent
force for communication. When not travelling to the country, they work in the
clinic and hospital and are always valuable cultural bridges between us and the
many Indian patients who come daily for treatment.

The Indian culture in Guatemala is a biophilic one, dedicated to life,
family God, crops, and the earth. It does not take readily to limiting life
and family, We sensed this early and we once thought that birth control would
not be acceptable in the highlands. However, with the passage of time and more
intensive thinking with the people, it became apparent that the Indian's ded-
ication to life can, and does, include family planning. There is an awareness
that, although the number of members of their race is an important considera-
tion, proper land use and health, particularly of the children, are related to
family size and sOicing. Again, our initial impression reflects the usual
situation where the "developed" think that the "underdeveloped" have no idea
of their needs and how to meet them. The Indians do understand that 6, 8 or
10 children inithe family will overtax their land and their food supply. They
are genuinely interested in planning their families, but strictly on their own
terms.

The family planning service is offered exclusively by Indian nurses. No
physician enters into the dialogue or decision-making unless the nurse requests
him to do so. Our nurses do not bluntly raise the subject of birth control,
explaining what can be done with a particular apparatus, pill or injection.
Instead, the nurse first sits down with the family and considers with them
their situation, who they think they are, and why they may wish to limit their
family. The technicalities are delayed until the family is deeply and fully
involved in the decision-making on its own terms. Once a decision is made for
family planning, the service is offered. Since the family makes the decision,
the drop-out rate is low.

The majority of families prefer the pill as a family planning method,
because of the eese of use, Intrauterine loops are encouraged but they are
not nearly so widely accepted as the pill, for several reasons, Inserting a
loop involves a vaginal examination, which is only reluctantly accepted by
Indian women, even if performed by a nurse of their own culture. Also, there
are rumors that the loop causes excessive bleeding and disrupts the normal
menstrual cycle. The injectable contraceptives are not encouraged because of
the possible serious side effects.

We have made no detailed study of the results of the family planning pro-
gram, but do know that there are fewer births per population and more realistic
spacing of children, particularly in the areas where more concentrated efforts
have been made,

The Indian must be convinced that there will be positive results, not
merely the limitation of offspring. The Indian is suspicious of other cultures
and their methods, To limit his numbers might lower his level of competitive-
ness with the ladinos (non-Indians). This idea, together with his traditional








- 15 -


reliance on his children to carry on when he is too old, makes him somewhat
reluctant to limit his family. If he is to be persuaded to consider family
planning, he must be assured that those who follow him will have adequate food
and land. He know that half his children die from disease, most of which is
linked with malnutrition, and so it must be demonstrated to him that having
fewer children can increase survival chances by ensuring better nutrition,
So agricultural extension, nutrition advice, and land reform programs must be
integral parts of the family planning concept. While we believe birth control
to be important, we must remind readers in the industrial countries that each
new Indian child in the Guatemalan highlands will use, in his lifetime, only a
tiny fraction of the irreplaceable natural resources (iron, aluminum, oil, etc.)
that a child born in the USA will use. It requires 25 tons of ore extracted
from the earth each year to sustain the average citizen of the USA, as contrast-
ed with a fraction of a ton for the average Indian of Guatemala.

Extension services agriculture and economics

The typical Indian farmer in the Guatemalan highlands is land-poor. Land
holdings are fractioned into tiny plots since, traditionally, the Indian farmer
divides his holdings equally among his sons. However, much of Guatemala is
covered by large estates and plantations, often left fallow by their indiffer-
ent absentee owners, who maintain titles only because of prestige or family
tradition or as a secure investment. Many Indians live on these estates as-
tenant farmers, owning no land at all.

Faced with such conditions, our extension program initially concentrated
on the obvious approaches the use of fertilizers, soil and crop improvement,
the introduction of better seeds, crop diversification, growing vegetables and
cold-weather fruits, chicken projects, veterinary medicine, and other efforts
that helped the subsistence farmer to produce more nourishing food for himself
and his family. Many of the farmers reached by the program have increased their
yields 2-3 times. In some cases, improvements have been even more dramatic.
While the program has neither time nor money for evaluation, it is obvious to
us that health has improved greatly in the areas most affected by our agricult-
ural projects, since nuch of the disease was related to poor resistance caused
by malnutrition.

These efforts, however, have their limitations. One must, of course,
respect cultural preferences and do so willingly. One example is maize, a
crop almost sacred to the Cakchiquel Indian. Even if he grows nothing else,
he always grows maize, consuming it as his staple diet. It would be futile to
try to persuade the Cakchiquel to eat higher protein food instead of maize.
In any case such a change is not necessary. The Indian is ready to grow and .
consume other food if it is feasible financially. So, rather than disparage
the maize tortilla, vhich is in any case more nutritious than bread made from
bleached white flour, the agricultural program has concentrated on improving
maize yields and satisfying the family needs, deferring the planting of other
crops. For the long term, the development of a high-lysene corn that can be
grown in the Guatemalan highland climate holds much promise.











Our program remains flexible with respect to the use of manufactured
agricultural accessories. Chemical fertilizers in particularly strongly tempt
us. Mechanical implements, such as tractors, are less attractive because of
the rugged terrain and the cost of buying and maintaining machinery. The pro-
gram has employed chemical fertilizers, but only after analysis of soil samples.
The fertilizers have definitely improved yields, but now, in view of the rapid
rise in price and the worldwide shortage of fertilizers, we have been reminded
once again of the hazards entailed by a development program that relies on
outside technology. Just as the medical approach must emphasize disease pre-
vention, releasing people from dependence upon manufactured pharmaceuticals,
so must the agricultural phase stress implements that the people can produce
themselves. So the program has now begun experimentation with efficient ways
of producing natural fertilizers that control the balance of the basic chemi-
cal elements.

The extension agronomists have received their training either with the
local-government agricultural extension program or within our own program, that
training being offered by more senior agronomists or Peace Corps volunteers.

Another limitation on the program is the poverty of the average small
farmer. He simply does not have the money to invest in new methods that he
considers risky. He finds loans extremely difficult to obtain, and when he does
get a loan it is usually from a private money-lender who charges intolerable
interest. To meet this need, the program set up a revolving loan fund to pro-
vide farmers with credit on easy terms for specific agricultural projects.
Gradually this revolving fund is being replaced by a local agricultural and
savings and loan cooperative. This cooperative is growing rapidly and already
includes many of the people involved in our other programs. The people them-
selves manage and control it.

The financing of the project

It may be asked how the medical and agriculture extension workers are
paid and how such a program can be locally self-sustaining. Currently, funds
for this extension program come from out-of-country foundations. We are, how-
ever, gradually working towards local funding, using the accumulated interest
fiom our various loan programs. Interest is charged on land and agricultural
loans and as these programs grow the returning interest will be sufficient to
pay the salaries of the various extension workers, thus making outside funding
unnecessary. Also, we have a long-term plan that involves a local agricultural
and savings and loan cooperative, mentioned above, with which we work very
closely. This cooperative, called Kato-Ki Quetzal, is rapidly expanding and
currently has more than 2,000 local members, all Indian. The services of this
.,,cooperative include the sale of agricultural supplies and the provision of
loans for agricultural investment (not including land loans, which are crvcred :
by ,he "ULEU" program discussed later). Their last inventory showed that'their
capital exceeded $200,000. The interest on the capital enables this large
cooperative to make its program self-sustaining. We have entered into a dialogue
with the board of directors of this cooperative and drawn up tentative plans for
uniting our total program with the cooperative, which uhd@it this new association
will be capable of offering total community services, A family or farmer will


- 16 -









- 17'-


then have available to them anything they might need, whether it be curative
medical service, family planning, land and fertilizer loans, agricultural ad-
vice, or any other need that might arise all from local funds, with no out-
side financial assistance.

In areas of the world where out-of-country sources of funds are not readily
available for starting and maintaining community programs, extension programs,
and loan projects, it may be possible to interest local government in making
funds available as grants or loans or to obtain money from the private sector
for rural investment. Each area has its unique situation, which it must eval-
uate in terms of culture, economy, tradition and local realities.

The lack of land to farm remains the most formidable obstacle to success
of our agricultural programs. Indeed, land hunger is the source of almost every
major problem in these Indian highlands. Since enormous numbers of farmers
own no land or own a piece so small that it is insufficient for family needs
(even with our improved techniques), the majority of upland Indians are forced
to migrate seasonally to the tropical coffee and cotton plantations on the
Pacific slopes. There, they receive low wages and live in squalid conditions.
This aggravates the primary health problems of infectious disease and malnutri-
tion and also absorbs the time that the farmer otherwise would spend on improv-
ing crop yields in his own highland village. Furthermore, when the farmer does
not own, or control through collectives, a suitable piece of land in the high-
lands, he has scant incentive to improve the land, If he were to improve the
soil by taking extensive conservation measures such as building terraces and
contour ditches, or by applying fertilizer and using a simple plow, the value
of the land would rise and the owner would demand more rent and even then
might not let the land to the same farmer. As a result, many Indian farmers
refuse to employ techniques that they know will improve land and crops.

Responding to this dire need, a new program is being established to pro-
vide loans to communities of farmers who wish to buy their own land, Loans are
made only to groups, so that communal farms will be encouraged, the cost of
extension services reduced, and the purchase of larger properties made possible.
The greater the amount of land being purchased the better the bargaining posi-
tion of the buyer. The revolving loan fund program is called "ULEU", which
means "land" in Cakchiquel, and is governed by a board of directors, who are
the extensionists and the representatives of the cooperatives, all local people.
The loans are long-term with low interest rates by Guatemalan standards. The
farmers do their own negotiating with the landlords to determine a sale price
and then choose one of two or three payment plans. The response already ob-
tained from groups of farmers has been much greater than the program can handle
financially at this time.

We by no means suggest that this approach is the ideal structure for land
reform, but it is a good option for a voluntary program that wishes to present
a show-case demonstration project. We hope to show that land reform can be
effective if it is embraced by a complex of community services as well as those
primarily agricultural. We also hope to demonstrate how closely land reform is
tied to public health. We, as sophisticated physicians, might not have seen the









- 18 -


connection ourselves if the Cakchiquel people had not pointed it out to us.
We who work in development are always indebted to the people who teach us through
their own responsiveness.

Our 12 years in Guatemala among these natural, loving, responsive and
industrious people, our friends the Cakchiquels, have wrought a major change
in our perceptions.. We came to cure the sick. Now we stay to help cure the
basic causes of sickness.

The reproducibility of the program

It is often asked whether the program can be reproduced elsewhere, in
Guatemala or in other countries. In Guatemala, the Government has gone beyond
the mere authorization of our community health promoter program and has used
it as a model for setting up the health training program in the Ministry of
Health, and, in fact, we were asked to help in the training of some of the
supervisors and trainers for this Government program. Whether the program
could be used outside Guatemala would depend on numerous factors such as pos-
sible local interference in this type of program by the local medical profes-
sionals, whether the government agrees with the idea of alternative health
services being offered, whether the people accept such alternatives, and var-
ious other local situations. We know that in-many countries those in both
national and local authority are seeking alternatives, recognizing that by no
stretch of the imagination can medical professionals really "care" for all the
people in need, particularly in the developing world with its large populations
and limited resources.

Guidelines for the public health of the rural poor
---- In poor areas of the world, as eslewhere, medicine must be practiced for
the benefit of the patient, not for the convenience and welfare of the doctor.
Public health work should begin with a dialogue with the people, encouraging
them to consider themselves and their situation.and to state their needs.
People everywhere have their own ideas about what should be done with their
lives, health and homes. The effective professional listens before he acts,
treats his patients as an equal in decision-making, and does not force his own
ideas and standards on those he serves.

---- A program that relies too heavily on outside technical and financial
assistance is destined for trouble. Almost any technically trained person,
regardless of nationality, is considered an outsider in the vast areas in-
habited by the rural poor, In many countries there are distinct racial, cult-
ural, and linguistic groupings carrying economic, political, and class impli-
cations. In addition, there is an enormous difference in outlook between the
urbanized technician and the rural poor. The technician is usually assured
of a physically comforatble existence while the poor person often struggles to
exist from day to day. This discrepancy alone accounts for enormous differences
" in perception. The poor man is no fool and he must be thoroughly convinced
that the technocrat's arguments are valid before he will risk deviation from
age-tested patterns of living, especially if he has to pay for the change.









- 18 -


connection ourselves if the Cakchiquel people had not pointed it out to us.
We who work in development are always indebted to the people who teach us through
their own responsiveness.

Our 12 years in Guatemala among these natural, loving, responsive and
industrious people, our friends the Cakchiquels, have wrought a major change
in our perceptions.. We came to cure the sick. Now we stay to help cure the
basic causes of sickness.

The reproducibility of the program

It is often asked whether the program can be reproduced elsewhere, in
Guatemala or in other countries. In Guatemala, the Government has gone beyond
the mere authorization of our community health promoter program and has used
it as a model for setting up the health training program in the Ministry of
Health, and, in fact, we were asked to help in the training of some of the
supervisors and trainers for this Government program. Whether the program
could be used outside Guatemala would depend on numerous factors such as pos-
sible local interference in this type of program by the local medical profes-
sionals, whether the government agrees with the idea of alternative health
services being offered, whether the people accept such alternatives, and var-
ious other local situations. We know that in-many countries those in both
national and local authority are seeking alternatives, recognizing that by no
stretch of the imagination can medical professionals really "care" for all the
people in need, particularly in the developing world with its large populations
and limited resources.

Guidelines for the public health of the rural poor
---- In poor areas of the world, as eslewhere, medicine must be practiced for
the benefit of the patient, not for the convenience and welfare of the doctor.
Public health work should begin with a dialogue with the people, encouraging
them to consider themselves and their situation.and to state their needs.
People everywhere have their own ideas about what should be done with their
lives, health and homes. The effective professional listens before he acts,
treats his patients as an equal in decision-making, and does not force his own
ideas and standards on those he serves.

---- A program that relies too heavily on outside technical and financial
assistance is destined for trouble. Almost any technically trained person,
regardless of nationality, is considered an outsider in the vast areas in-
habited by the rural poor, In many countries there are distinct racial, cult-
ural, and linguistic groupings carrying economic, political, and class impli-
cations. In addition, there is an enormous difference in outlook between the
urbanized technician and the rural poor. The technician is usually assured
of a physically comforatble existence while the poor person often struggles to
exist from day to day. This discrepancy alone accounts for enormous differences
" in perception. The poor man is no fool and he must be thoroughly convinced
that the technocrat's arguments are valid before he will risk deviation from
age-tested patterns of living, especially if he has to pay for the change.










19 -

Nationalism is perhaps one of the most difficult problems facing innovat-
ors in a developing country. Most native professionals are as alien and sus-
pect to the rural poor as the foreign professionals, separated from the people
as they often are by formidable racial, linguistic, and cultural barriers,
National professionals, whether they be priest, preacher, doctor, or engineer,
can exert much more influence over their own people than foreigners can. These
professionals are often quick to adopt nationalist attitudes when they find
their own power, prestige, and privileges threatened by a poprAar program -
particularly one initiated by foreigners. The greatest challenge to such a
program is how to achieve acceptability in the eyes of the national elite
without being stifled by the professional bureaucracies. Control of a program
should be vested in the people the program is designed to serve and should
never be dominated by the aristocrats.

---- Beware of the cry for "higher standards". Professionals love to
boost "standards" for any program,.thereby driving up the cost of equipment
and expertise and putting the program beyond the reach of a humble community.
Quality should never be equated with high cost. Unfortunately, *te medical
profession has waged an extensive propaganda campaign in this direction. They
would have us believe, for instance, that expensive open-heart surgery is the
pinnacle of accomplishment in medicine. However, in three-quarters of the
world, disease that could easily and inexpensively be treated runs rampant.
If the medical profession declines to tackle the basic ailments that it already
knows how to treat and prevent, then it is not entitled to indulge in extrava-
gantly expensive techniques for le rich few.

---- A public health program aimed exclusively at curing the sick will
have little effect on the health of the rural poor. A program that includes
preventive medicine, nutrition, and hygiene will fare somewhat better, but
it too will fail to do the job. A program expanded by family planning and
earnest work on increasing crop yields on the family farm will accomplish more.
However, a program that fails to deal with the fundamental problem ownership
of the land will meet with no more than modest success.

--- The truly successful public health program among the rural poor must
tackle basic problems of economic and political development. This by no means
indicates that program leaders should plunge into controversial national issues
or ally themselves with specific political movements. A program must be de-
tached from factional politics if it is to respond to the people without power.
Yet, there are levels below those of national politics where the people can
learn to control their own lives through politics and economics. A cooperative
is a good example, since it responds to financial need and builds local leader-
ship. The cooperative is no panacea, but it is often a practical move in the
right direction, laying a foundation for people power in the politics of sur-
vival.

---- The stronger the orientation toward those being served, the more
successful the program is likely to be. The essential first steps are: listen
to the people, appreciate them, love them, take them into your confidence, and
try to be at one with them.










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-- Avoid offering service on your terms only. If you do a demographic
survey, be sure that it includes the questions, "What do you think your needs
are?" and "How do you think we can help you?"

--- Local community health committees should be organized and functioning
before the first aspirin or dressing is handed out. The committees should
then select the people to be trained to offer service, supervise them, disci-
pline them, report on them, and control them. Committees should set the
standards of service and the prices to be charged.

-- The outside help needed in materials, manpower, direction, and super-
vision should always conform to local custom and tradition. The technician
or physician should dedicate himself to training local counterparts as quickly
as possible.

---- Training programs should permit trainees to continue their usual
work, family life and community relationships, with absence from home kept
to a minimum. Training programs at distant centers often disrupt family and
community links and may corrupt the trainee by exposure to a foreign culture
and life style that makes return to his community difficult and sometimes
impossible.

-- Medical training demands the use of clinical teaching on patients in
either a dispensary or hospital, so that the clinical picture is clearly seen,
appreciated and understood.

--- The treatment of ailments should be according to symptoms, not diag-
nosis. Even people with sophisticated schooling often misinterpret symptoms
when making a diagnosis. Our experience is that symptom treatment results in
relatively low error, considering that most medical problems are simple and,
in the natural course of events, heal themselves.

--- Trainees must be taught what not to treat as well as what to treat
and how. The future of non-professional curing demands that this concept
should not be violated.

.--- The supervision and continued education of lay curers is essential,
the nature of the supervision depending on local conditions. We require reg-
ular attendance at clinical training sessions, regular examinations, regular
visits by the supervisor to the health promoter's home, and regular reports
from tocal community health committees on the caliber of the health promoter's
work, its acceptance, and the range of fees charged.

--- The fees should be decided locally, and the central agency should
never put anyone on the payroll. The community being served pays with no
exceptions. The only people on the central payroll should be the trainers
and supervisors, and no one else. Curative medical services should pay for
themselves. In a total program, income should cover all costs, with the
proviso that since certain individuals cannot pay at the time of treatment










21 -

a credit system must be introduced, with generous use of the "Robin Hood"
principle, namely, charging higher fees to those who can afford to pay and
asking considerably lower fees from the genuinely poor,

---- Dependence on outside finances saps local responsibility and may
jeopardize the supply of services and materials.

--- Health has many facets economic, political and social. Each must
be taken into account when the epidemiology of any human health problem is
being considered. Proper care for any ailment physical or social demands
dedication to the treatment of causes, not merely the amelioration of current
pain.




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