Worsening economic injustice has become a fact of life in our current world and has a profound effect on health and health care in many countries. Dysfunctional health systems exist in most areas of the world. Many impoverished countries, especially those in Sub-Saharan Africa, spend so little on health care that it is impossible to provide even the most basic services for their populations. Many middle-income countries have complicated insurance systems or cover only salaried workers, leaving the majority of the population with very poor access to care. In recent years there has been increasing discussion and activism around health inequities on an international level. An example is the People’s Health Movement, a global network bringing together grassroots health activists, civil society organizations and academic institutions from around the world, particularly from low and middle income countries.

Founded in 2000 and with a current presence in 70 countries, the People’s Health Movement is continuing to grow. Doctors for Global Health (DGH) is part of the USA Circle of People’s Health Movement. DGH was itself formed in 1995 to support work in El Salvador, training health promoters in communities that had been most devastated by the long civil war that ended in 1992. Since its inception, DGH has accompanied communities in Argentina, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Peru, Uganda and the United States. We work to improve the health and well-being of these communities by increasing access to quality health care, developing educational opportunities and raising awareness of health and other human rights. Members of DGH are health professionals, students, educators, artists, attorneys, engineers, retirees and others. The organization builds longterm relationships between people and communities around the world to find effective solutions to health and social justice issues. The founder of DGH, Dr. Lanny Smith, began to use the term “liberation medicine” to describe the work he and other volunteers were doing in these communities. In a 1999 DGH newsletter, he describes the way the idea came to him:

“I was searching for an adequate definition for the kind of medicine we had been practicing in El Salvador. I also wanted to include the larger component of local and international education and solidarity that our work had come to involve. The defining word came to me while reading Father Ignacio Martin-Baro’s book, Writings for a Liberation Psychology. While ostensibly about psychology, I found the book’s message applicable to medicine as a whole. Fr. Martin-Baro wrote, ‘In our case more than anyone else’s, the principle holds that the concern of the social scientist should not be so much to explain the world as to change it.’ It seemed to me that Martin-Baro was describing the kind of medicine we had been attempting to pursue in Morazán. Thus came the definition of liberation medicine that we at DGH have been using: The conscious, conscientious use of health to promote human dignity and social justice. “

Liberation medicine clearly echoes liberation theology, the movement that interpreted Jesus’ teaching as a radical call for the equality of all people and to care for one another. Liberation theology began in the 1960’s within the Catholic Church after Vatican II and the Bishops’ Conference in Medellín, Colombia. Martin-Baro was greatly influenced by the liberation theology movement and pointed to it as his inspiration for liberation psychology. A useful methodology with or without the religious angle, liberation theology calls for observation, reflection and action. Whenever possible this process should emphasize accompanying of the disempowered.

The work of DGH in Mexico is an example of our philosophy of liberation medicine and accompaniment. Mexico is a middle-income country with a very high degree of socioeconomic inequality. Despite some reforms, Mexico’s health care system is far from covering the whole population.

A baby in Chiapas being vaccinated. Courtesy of Linnea Capps

Furthermore, there is also long-standing marginalization of its many indigenous peoples. On January 1, 1994, the day that North American Free Trade Agreement took effect, a then-unknown rebel group in the southern state of Chiapas, the Zapatistas, began an uprising in defense of the rights of indigenous people. A charismatic hooded Zapatista leader, Subcomandante Marcos, became the iconic spokesman for why the revolution was necessary. His many writings proclaimed with great passion and eloquence that poverty, discrimination, poor education, the unfair distribution of land, the lack of true participatory democracy, and inadequate health services were among the underlying causes that prompted the revolt. Negotiations during the early years after the rebellion resulted in the San Andrés Accords in 1996. This agreement would have allowed for more autonomous community decisionmaking and redistribution of land in the conflict zones, but it was never converted into laws. In response, the Zapatistas declared the Mexican government the Mal Gobierno (Bad Government) and vowed to continue building their new society “in resistance,” which for them means refusing all government services, including education and health care, in favor of creating independent structures.

Consequently, the autonomous communities have avoided using Mexican government health care and have developed their own system that includes many essential elements: vaccination campaigns and other public health measures, simple clinics run by health promoters, and a few more sophisticated clinics and hospitals. There have been important successes: Vaccine coverage, for example, is excellent in many of the communities. The challenge for all of these initiatives is that many of the Zapatista communities are very small and geographically isolated. Teachers and health promoters are volunteers who also must care for their own families and their corn or coffee crops. Health care especially is expensive, and the communities can’t pay the costs of even some of the simplest medical treatments.

DGH works in several Zapatista communities in partnership with Hospital San Carlos, located in Altamirano, Chiapas. DGH supports the community health program of the hospital and also sends volunteers to work in the hospital and the communities. Hospital San Carlos was founded in 1969 by American nuns in order to serve the local population of indigenous Mayans, and was handed over shortly afterward to Mexican nuns of the Daughters of Charity of St. Vincent de Paul.

DGH supports the community health program of the hospital, which works in five of the autonomous Zapatista municipalities. The goal of the program is to train village health workers and promoters. The Mexican physician who directs this program is training and supervising approximately 100 health promoters among these municipalities. These communities have a very strong autonomous governing structure, the Junta de Buen Gobierno (Good Government Council) and all of the training and health work is approved by the the council. Volunteers who want to work in the communities must be aware of the cultural issues and linguistic barriers and any new project must be formally presented to the JBG and be approved before any work in the community can start.

Eladio, the Mexican physician who directs the community work writes: “We, the outsiders, identify with their demands for justice, freedom, and democracy. We unite with them to strengthen their struggles to defend their culture. We support them in defending their territory, disobeying, and resisting. Much of this support is simply being there, eating and sleeping in their homes, and talking with them about their daily lives—how they plant corn and beans, or harvest coffee. We know their families; we know why they are often ill with problems that don’t affect more prosperous communities. We see how much more difficult than ours their life is.”

The Zapatista community health commissions are responsible for designing their autonomous model of health. We make suggestions and give technical advice, but we try not to impose our own ideas.

Progress is very slow. The cultural and linguistic differences are challenges for us and for the promoters. There is still a large Mexican military presence in Chiapas and various paramilitary groups operating with impunity. So the threat of conflict is always present. We know that popular education takes time but we see the results as the promoters learn to confront the health problems in their communities. We remain committed to accompanying them over the coming years and supporting their progress.

More information: www.dghonline.org, www.phmovement.org.