In a country like the Philippines where approximately 70% of the population are poor peasants and another 20°/o belong to the urban poor, a Western-style, profit-oriented, institutionalized and urban concentrated health system is available only to upper 10°/o of the population. While health care is practically unavailable in vast rural areas and in the sprawling urban shanty towns, the governments pours money into multi-million dollar prestige projects such as the Philippine Heart Center Foundation in Manila. Meanwhile, thousands die from malnutrition and lack of potable water. This lack of adequate health care is clearly. linked to the political and economic structures of the country. The main causes of disease and death can be traced back to the unequal distribution of income and goods. Without a radical restructuring of the political and economic system there can be no long term solution to the health needs of the vast majority of the people. At the same time, the restructuring of the health care system at the micro-level can help to bring about change in the political and economic sectors. This, at least, is the reasoning of many of those involved in developing alternative health care in many parts of the Philippines. Much of this work is being carried out under the auspices of religious groups such as the Medical Mission Sisters and the Rural Missionaries. This is partly due to the fact that under the present martial law regime, church groups are among the few which still have relative freedom of movement and action.
Community based health programs are being developed in wide rural areas of the country as well as in the urban slums. They have in common the training of local para-medics, a majority of whom are women. In addition to this training, most of the programs combine political and economic aspects designed to constitute a challenge to the status quo and are often looked on with suspicion by the ruling elite.
We are presenting here an article describing a health program in an urban slum in the Philippines : the training of local katiwalas or "first trustees of health". The experience of the katiwalas shows that women who come from the most disadvantaged sectors of the Third World can become effective agents of health. Moreover, this program has implications for the economic situation and self-determination of both the katiwalas and the people in their communities. The article was written by Irene M. Santiago, a Filipina journalist, and was translated and adapted for publication in the October 1977 issue of Famille et Developpement (Dakar, Senegal). The present text was translated by ISIS. Credit is due to Ann Leonard and Cycle Publishers for providing the original text.
Liona Briones, Lita Remo and Gabriella Arnaiz used to be in the same situation as most of the other women in the slums which ooze out around the city of Davao in Southern Mindanao, the largest of the Philippine islands. Their families barely had enough to live on even when the father was working in one of the factories or on the docks. And the threat of being expelled from their miserable hut hung over them constantly.
Liona, Lita and Gabriella are now different from the other women in their community. They have become medical auxiliaries - "Katiwalas" - the first ones in the Philippines. By doing this they can not only increase the meagre family income but also help their neighbors with nutrition, hygiene, family planning and treating illnesses. This experience shows how even an extremely poor community can considerably improve its standard of health at very little cost, without becoming too dependent upon outside services.
In Davao, 17,000 families or 100,000 people out of a total population of 500,000 live in absolute poverty, with an income of about 55 US cents per day and per family.
Endemic malnutrition
They live in overpopulated areas which are deprived of running water, drains and toilets. Many of the dwellings have no electricity. The average family of six usually lives crowded into a miserable one-room hut which easily catches tire. In these appalling health conditions, 95°/o of the children are afflicted by some kind of parasite. Malnutrition is endemic (75°/o of children under 5 are malnourished) and tuberculosis is pervasive. There is only one nurse for 40.000 inhabitants ! Since they have neither the means to go to the hospital nor to consult a private doctor, the slum-dwellers of Davao usually go to traditional healers when they are sick.
In 1967 a group from the Christian Family Movement and a Redemptorist priest decided that some kind of action, however small, was better than nothing. They opened a free medical clinic and a dental service in several rooms on the ground floor of a monastery. The volunteer doctors, dentists and nurses hardly had time to install themselves before huge long lines of women with their sick children began to appear on the days of free consultations (Monday and Thursday afternoons). Very soon more than 300 families were being treated there regularly.
After giving free health care for two years, the workers at the clinic realized that these charitable services only helped to increase the dependency of poor people, and that in fact they were only reaching a tiny portion of the population.
The Christian Family Movement decided to withdraw and the clinic was taken over by the inhabitants themselves who formed into a mutual aid society. For less than 5 US cents anyone could become a member of the medical cooperative, and the monthly dues for a whole family was only 2 US cents. Apart from the membership fee, the only requirement was that a member of the family - usually the mother - had to take part in a seminar which would explain the tasks and responsibilities of those concerned. Membership of the medical cooperative gave each family the right to receive medical and dental care at the clinic and enabled them to buy medicines at a quarter of the price they were sold at in the pharmacies. In addition families could get financial assistance for cases when hospitalization was indispensable.
The clinic was such a success that in addition to the 750 families of the cooperative, there was a long waiting list of families who wished to join. To satisfy everybody, those responsible first thought of opening ·fourteen sub-clinics in the areas served by the cooperative. But since the number of medical volunteers had not really increased, this project was obviously impossible. Another solution had to be found.
It was then that the idea of training members of the cooperative was born.
In each of the fourteen districts served by the medical cooperative two people were nominated to be trained as medical assistants. The selection was made not only on the basis of their ability to work closely with the population, but also of a genuine motivation. It was also required that they be able to read and write, that is that they had completed at least primary school. (In fact, the literacy rate in the Philippines is quite high compared to that of other developing countries.)
The group which appeared for training in January 1972 was certainly mixed. Of the thirty people selected for training, only two were men : a student and an unskilled worker. Apart from one teacher who was curious to find out what the training would be like, all the others were mothers from the slums served by the cooperative. Most of these women had worked to supplement their husbands' meagre income by selling fish or firewood, or by working as domestics, etc.
The first stage of training - the most important - consisted in establishing confidence on all sides. At the beginning, the participants were afraid to ask questions for fear of showing their ignorance. But the people teaching knew that the success of the program would depend on the participants' ability to express their needs, to talk about their resentments, to ask questions and to give answers in an atmosphere of mutual acceptance and confidence. In order to achieve this, a fundamental change in thinking was necessary, on the part of both teachers and students : the teacher had to stop thinking that the student was a sort of container into which one empties knowledge, and the student to stop thinking that she had nothing to teach or offer this prestigious teacher figure.
To emphasise the fact that they had much to learn from their "students", the teachers (doctors, nurses, etc.) called themselves teacher-students and immediately called the future auxiliaries student-teachers. This simple but ingenious idea was inspired from the theory of Paulo Freire who used this approach very successfully among the peasants of Brazil and Chile.
The training lasted 24 weeks, one session a week on Saturdays from 1-5 o'clock in rooms lent by the Ministry of Health. Training was given by seven teacher-students who worked among the student-teachers rather than giving lectures. The participants used Visayan (a local dialect) or Tagalog (national language of the Philippines). The use of national languages turned out to be very important. The student- teachers usually felt much more comfortable using their own language than the teacher-students. Each person taught someone else something, and the atmosphere became gradually more relaxed. Four basic rules for teaching were adopted :
- never avoid answering a question
- never say "this is too difficult for you, we'll come back to it later" (a paternalistic and condescending attitude);
- speak clearly and straightforwardly; take examples from everyday life;
- as far as possible, turn questions back to the student teachers to see if they have understood.
After four sessions the teacher-students had the impression that the student-teachers were already more relaxed.
The student-teachers took part in the decisions concerning their training. They made their own school rules for themselves, deciding on disciplinary action if necessary (e.g., unjustifiable absence could mean expulsion from the course), they determined the length of the sessions. They decided to wear uniforms in order to look more professional. They also called themselves Kaunaunahang Katiwala Ng Kalusugan, which means "First Trustee of Health". They were, if you like, "bearers" of health into their community.
The teacher-students emphasized especially preventive medicine: hygiene, immunization, nutrition and family planning. It is in these areas that the medical auxiliaries could certainly be most effective.
Starting with expressed needs
But the student-teachers were well acquainted with conditions in the slums and were particularly preoccupied with the most immediate needs. They wanted to know how to cure fevers, headaches, abdominal pains, intestinal parasites, coughs, colds and diarrhea. Following the method of starting with expressed needs, they all decided to put prevention second and to attack the most urgent needs.
The six-month course cost only US $ 135 for everything. Gifts of money and equipment (e .g., thermometers) were made by certain members of the Davao community. All the teachers (doctors, nurses, medical technicians and other specialists) gave their services free. Of the 30 Katiwalas who took the first course, 28 completed it. At present, 61 out of the 91 who have taken the course (there have been three altogether) are practicing in the local community.
At the time of receiving the diploma, each Katiwala also received a manual written in Visayan and a small case containing a thermometer, aspirin, bandages and other first aid material. The manual ditfers from ordinary medical manuals, in that it deals more with analysis of symptoms, which enables the Katiwalas to diagnose problems, more easily.
Each Katiwala is responsible for 25 to 50 families in the area where she lives. Although they are responsible for the health of the families who are members of the medical cooperative, they also attend non-members which make up about 80°/o in some districts. Non-members can receive treatment at the cooperative clinic, but have to pay more than the members.
Once a week each Katiwala works at the clinic as a medical helper during the regular Monday and Thursday opening times. Some of her tasks are : weighing babies, analysing feces and urine, taking temperatures and blood pressure, giving injections, dispensing medicines, dressing wounds, and keeping the patients' records up to date.
No patient can see a doctor without first seeing the Katiwala of the district, who decides whether or not the patient should see the doctor. If it's not necessary, she will prescribe the appropriate treatment or medicine. Medicines are available at the pharmacy of the cooperative at wholesale prices. Only the more expensive antibiotics are subsidized up to 50% by the cooperative. If a visit to the doctor is necessary, the Katiwala will issue an appointment card.
Bold initiatives
The most common illnesses treated by the Katiwalas are coughs and colds, fevers and diarrhea. But they are gradually dealing more and more with environmental hygiene (latrines, · disposal of used water, etc .), mass vaccinations, nutrition, education and family planning. For example, the Katiwalas teach their neighbors how to build cheap toilets, septic pits, and wells for compost.
They stress the need to use potable water during their house to house visits and urge the vaccination of children and pregnant
women, since neo-natal tetanus is still one of the most frequent causes of death in new-born babies. They regularly organize meetings with mothers to talk about nutrition and family planning
The Katiwalas are also trained in methods of childbirth, but they can only do this if a doctor has already examined the pregnant woman and found nothing abnormal. The Katiwalas frequently visit women to give pre- and post-natal examinations.
Since the slum-dwellers are often ignorant of the administrative procedures necessary to give admittance to hospital, they are appreciative of help from the Katiwalas in doing all this for them.
The most active and imaginative Katiwalas have taken some bold initiatives of their own . Thus, for example, Liona Briones has set up a mini-clinic in front of her house where her neighbors can come for examinations and consultations. She keeps a very small stock of the most common medicines such as cough syrups and pain killers which she is authorized to dispense.
A Katiwala's income depends a lot on the amount of time she spends working. The average monthly income is about US $ 5.00 but a Katiwala who works full time can earn almost four times this amount, or three times the salary of a domestic worker. This is important in districts where unemployment is endemic and where many fathers of families spend months on end without earning any money
A Regular Salary
The fact that the Katiwalas are obliged to spend at least half a day at the clinic each week means that they are receiving a kind of continuous training. Twice a month the Katiwalas have work sessions with the medical personnel. During these meetings the Katiwalas give the details of the cases they have dealt with in the previous two weeks, and an account of the kind of treatment they gave. These training and sharing sessions enable them to continuously improve their knowledge. Permanent training is a very important aspect of the whole experience
It should be also pointed out that the Katiwala operation has helped to improve the situation of women in the slums in many other ways. For instance, on the first floor of the clinic there are 80 women at work. These women are sewing, making beautiful bedspreads, handbags and other products which are immediately sold in Davao, Cebu and Manila, the capital of the Philippines.
This sewing cooperative saw the light of day as soon as it became obvious that many Katiwalas and slum-dweller women wanted to increase their income in order to look after their families better. In the sewing cooperative women can earn a regular salary according to their needs and responsibilities. All the profits from the workshop are transferred to the medical cooperative to help pay for the subsidized medicines and certain other expenses such as the salary of the caretaker.
The Katiwalas, thanks to their slum background, have been able to counteract the influence of certain charlatan-healers and of traditional superstitions. Among the latter, the following can be noted : the notion that intestinal worms (ascaris) aid digestion; that certain spirits cause illnesses; that, since God fixes the number of children who will be born, family planning is useless; that persistent fevers are caused by bone dislocation.
What motivates women to undertake this kind of work ? Alice Alarde, an ex-president of the Katiwalas association, says that she had wanted to become a nurse or doctor but that, since she was unable to pay for further studies, she never went beyond secondary school. "Now, as a Katiwala, I can aid the sick", says Alice, "something I never thought it would be possible for me to do".
Thanks to their new skills, the Katiwalas are respected in their community. Their neighbors frequently come to consult them. As one of them said : "Even the teacher comes to see me to receive advice on family planning".
Most of the Katiwalas are like Gabriella Arnaiz. They remember the anxiety and the feeling of despair which gripped them when someone in their family fell ill. The feeling of being able to control their destiny, of being able to effectively combat disease, has become of fundamental importance for them : "I was like the others, I went crazy when one of the kids got sick", says Gabriella, "but now I can help my neighbors and ease their pain".