PHM Activist Dr. Ravi Narayan @ Liberation Medicine Course
Story originally posted by Matt Anderson on the Social Medicine Portal.
On Friday, October 8, Dr. Ravi Narayan of the People’s Health Movement visited the Bronx to talk about his work; he spoke as part of the Liberation Medicine Course run by Dr. Lanny Smith. The talk took place in Dr. Smith’s apartment where some 30 students and health activists gathered to hear Dr. Narayan. Food was provided by Dr. Mario Chavero, a visiting psychiatrist from Rosario, Argentina.
Participants in the Liberation Medicine Course. Dr. Narayan in black Tshirt.
Dr. Narayan began by noting that this was his second trip to the Bronx. He had spoken to students at Albert Einstein College of Medicine in 2003 when he and his wife, Thelma, had presented at the GHEC conference in New York. He was here now as adviser to the Obama Administration’s Inter-Faith Initiative and also to consult with PAHO about community health. He seemed a bit bemused by the fact he had been invited to work on faith-based topics, but learned he had been chosen because of his work (see below) in getting several religious groups in India to work together.
Dr. Narayan told us he represents a collective of people still enthusiastic about the goal of Health for All.
Medical Training and Work in Refugee Camps
Dr. Narayan is a physician and graduated from medical school in Bangalore in 1971. After graduation and “quite by accident” he went to work in refugee camps along the border with Eastern Pakistan (now Bangladesh). As background, he told us that there were nine million refugees who walked across border into India because of a rampage by the Pakistani Army. Their sole crime was to participate in a democratic election. In this election the East Pakistanis (the majority in Pakistan) had voted for their own leader; in principle he was to become the Prime Minister. The West Pakistanis objected and sent the army to East Pakistan. The refugees walked across the border into western India where the government set up some thousand camps. A liberation struggle developed in East Pakistan which would eventually become the independent state of Bangladesh. Seven to eight months after this exodus, the refugees returned home.
The experience of working in the camps caused a paradigm shift in his thinking. Were it not for this paradigm shift, he might have ended up on the east coast of the US, the goal of many well-educated Indian physicians. In fact, he noted with a wry smile, during this trip to the US he had been meeting with many of his old medical school classmates. Instead of coming to the US, however, he had been transformed by the “very human experience” of being a doctor working with a community. He had learned to listen, to see patients as participants in their own lives, to consider mental health, and to look at the social context of health. He had been exposed to a series of experiences – genocide, rape – which had been absent from the medical school curriculum. He was challenged to look at social, political, economic determinants that he learned very little about in medical school.
After working in the camps, he returned to the medical college and specialized in public health and preventive medicine. These were, he noted, the only specialties that would allow him to continue to work with people in the community as opposed to working in the hospital or outpatient clinic. He would later get a public health degree from the London School of Tropical Medicine and Hygiene and do further studies at the All-India Medical School (“India’s Johns Hopkins”).
Teaching Community Medicine
For 10 years he had taught in the St. John’s Medical School Department of Community Medicine trying to replicate for students his experience in the community of the camps. He found lots of support from young doctors who had been involved in natural disasters and been transformed by “the moving experience” of working with a community. His wife, Thelma, had this type of experience when she worked doing disaster relief. While he described teaching this course as “10 years of great fun”, there were problems. The Department worked in five clusters of villages and they kept coming across problems, such as caste and gender, which were not medical. It was frustrating for the faculty not to be able to offer students “solutions” to these problems. Dr. Narayan cited a specific example. They used growth charts (called the “Road to Health”) to detect malnutrition in children. Over time it became clear that the children of dalits, the lowest case group, always had third degree malnutrition. “No matter what you did” it proved impossible to improve their nutritional status. The biomedical tools just did not work. They tried community-based interventions; he had attempted to organize unions. But this was a dangerous activity and he had been accused of being a Marxist. At the time, he said, he didn’t know what this meant, but he had read up on Marxism subsequently.
The faculty was frustrated and disturbed by the failure of biomedical solutions. They realized over time that medical schools always limited in their analysis to the biomedical part of problem and this led, inevitably, to a technical solution (usually a drug or vaccine). Even when a social determinant was apparent, physicians kept it out of their thinking. After all, dealing with determinants was not taught in medical schools. They were also concerned that although they started each course with a definition of health, in the end the curriculum was entirely about ill-being. Finally, they were bothered by medicine’s orientation towards individual problems with no appreciation of collective responses.
Foundation of SOCHARA
In 1984 Dr. Narayan and three other members of the department left the medical school (“this symbolized our walking out of the biomedical model”) and established the Community Health Cell, SOCHARA. Other faculty would join them later. Rather than dealing with health problems, they wanted to work with people interested in wellbeing. They did not want to work with dispensaries, hospitals or drugs. Rather, the wanted to work on health, wellbeing, and social determinants; they are not so concerned with medical problems.
Their focus shifted from doctors and nurses and they began to work with farmers, teachers, women, and street children. By 1990 SOCHARA was busy. It had grown by word of mouth and they were very happy doing this sort of work. They purposely avoided an academic institutional affiliation and they did not start any programs of their own. Rather they helped people to form their own networks.
But by 1990 they became increasingly aware of how decisions made in Delhi and elsewhere (he mentioned Washington) were affecting them. Malnutrition in Bangalore began to increase because millet was no long available cheaply on the local market; it was being exported. Development did not seem relevant to the people in the area, rather it benefitted other people who lived someplace else. The example of millet export showed how agricultural policy was relevant to malnutrition. They set out to study economics and social conditions. SOCHARA by this time had an extensive network of alumni and contacts, so when they came across something they did not understand, they found a colleague who was an expert. Sometimes what they learned made sense and sometimes it didn’t. They often felt that the social sciences helped to understand what was going on, but didn’t provide tools to make things better.
In 1992 India accepted a World Bank’s Structural Adjustment Program and made significant cuts in social benefits. The result was to further polarize society. Bangalore, Dr. Narayan’s home, was now the most globalized city in the world. The expression “to be Bangalored” meant to have your job moved to India. Around his family home you could find all major multinationals within walking distance. But whereas 400 million Indians were now living in the globalized world (“I can eat McDonald’s or Kentucky Friend Chicken and wear Nike shoes”), 800 million Indians “don’t even get the basics.” There are two Indias now.
People’s Health Movement in India
By 1999 SOCHARA had come to feel the need for a countervailing power which could speak truth to power from the bottom up. This was the impetus for the formation of the People’s Health Movement in India. During its history SOCHARA had worked with 18 large networks and in 2000 they called them together in a meeting in Hydrabad. It was a diverse group which included Marxists, Gandhians, and Christians. Five representatives of each network assembled on April 7th 2000, divided themselves into working groups, and produced “five little books.” These book examined what globalization had done to health, to primary health care, and to basic needs. The content of the books was then converted into popular formats (cartoons, songs) and used to mobilize some 300 communities. In December 2000, some 2500 people packed into four trains and came to Calcutta for first national People’s Health Assembly; this launched the national PHM of India.
As an interesting side note, Dr. Narayan briefly discussed the armed resistance to British colonial rule. He noted that although we, as Americans, would be surely surprised to hear this, it was not Gandhi who had forced the English out. Rather the English left because large sections of the army had deserted (to join the armed resistance) and the country had become ungovernable. “As a result, we went from one group of Brahmins [i.e. the British], to another and the revolution was incomplete.” He sees this failure as the reason that 1/3 of India is currently under a Maoist insurgency and they (like many other progressives) are often accused of being Maoists.
Formation of an international People’s Health Movement
“Of course, internationally we were not alone.” Similar initiatives had been going on in a number of countries and in December 2000 a meeting was held in Savar, Bangladesh which founded the international PHM. The resultant People’s Health Charter went beyond Alma Ata. He is in love with the charter: “2 pages of problems and 6 pages on how to fix it.”
Speaking of PHM, Dr. Narayan noted: “It’s a movement, you can’t pay to join it.” The work of the People’s Health Movement has evolved into four main activities: 1) the development of country circles which range from a few people who communicate by list serves to large national organizations with state and district level committees (India), 2) the publication of Global Health Watch every five years, 3) holding of International Peoples Health Universities, 7-10 day training programs for activists from around the world, and 4) the organization of the international People’s Health Assembly every five years.
After 10 years of existence, he felt that PHM is now getting to be well known. Many articles have been published about PHM or by PHM members. Discussion of PHM now appears in textbooks of global health. PHM has been described as the “globalization of health solidarity from below” a description he feels is apt. He now devotes his energies to talking to students in public health and challenges them that: “If your professors aren’t teaching you about PHM, perhaps they are dinosaurs.”
Questions from the Students
“You make it sound easy, but surely there were difficulties.” Dr. Narayan noted that he had offered us just a ‘short story’ about their work, and that yes, it was a challenge and a struggle. They had been victims of political persecution. But he also noted that one of the largest challenges was to change what is inside of ourselves. They have a fellowship program (Community Health Learning Program) which is a six week experience of the movement. Two weeks are spent at SOCHARA and there are two additional two week placements elsewhere. This fellowship allows people to become familiar with their work. Their principles for selecting people are two. They only take people who are confused; “if you’re not confused, you don’t need us to teach you.” They also feel that you can’t be part of the solution unless you realize you are part of the problem. Fellows, for example, need to unlearn professional biases. “You need to see every person as a participant.” But he also stressed the importance of professionals sharing their knowledge (to demystify things) as well as accepting that other people had expertise that they did not. There needs to “eyeball to eyeball” communication, i.e. communication between equals.
“How did SOCARA succeed in getting diverse groups to work together?” Dr. Narayan addressed this question by pointing to some of the traps into which organizations fall. The first was elite capture which occurs when an elite group (perhaps the academics) takes over an organization and other groups are marginalized. There was ideological capture in which different groups competed to see who was the most left. He feels it is important to ask: “Is this policy pro-people or pro-market?” Finally, there was individual capture in which a charismatic person takes over the organization.
“How did you get paid when you worked at SOCHARA?” First, they had to accept that they wouldn’t earn as much they would in other areas. Second, they don’t require people to be full time; there are many degrees of participation in SOCHARA. Salaried staff were actually quite few. When he was the PHM global coordinator, the movement only had four salaried people in the entire world.
Two other speakers followed Dr. Narayan. Samuel Mwenda Rukunga, from PHM Kenya, discussed their work providing health care and advocacy in the context of religious health care institutions. Manoj Kurian MD, Program Executive of Health and Healing, World Council of Churchs discussed how religious faith informed his advocacy for health for all.
Interested readers may also want to look at our interview with Dr. Narayan published in 2005 in Social Medicine.