ADVOCACIES: Neither empowerment nor medical education is neutral

(Speech delivered at the opening of the two-day Association of Philippine Medical Colleges Student Network Regional Convention hosted by the Davao Medical School Foundation on November 6, 2015).

DAVAO CITY (MindaNews/09 November) — It is with great honor and pride that I accept the invitation to be speaker on this occasion. I take the liberty to join the students of Davao Medical School Foundation in welcoming the participants of this convention in Davao City. Your theme, “I am APMC, Involved and Empowered,” is a fitting tribute to the Association of Philippine Medical Colleges (APMC). Indeed APMC is an empowered entity that has guided the medical students through the years of its existence. Before I start, please take note of the disclaimer. The ideas presented do not belong to APMC or DMSF.

Friends, colleagues and future colleagues, I have only five key messages for this talk:

  1. Empowerment is something that the authentic issue bearers take into their own hands and not something carefully doled out.
  2. Community Empowerment is people gaining full control over their own lives.
  3. Critical Analysis is crucial to Community Empowerment.
  4. Empowerment is not neutral and neither is medical education.
  5. Physicians, as well as medical students, can be as empowered as being the game-changers or even heroes.

Message 1: Empowerment is something that the authentic issue bearers take into their own hands and not carefully doled out.

I tried to google the term EMPOWERMENT and the typical definition is “to give power or authority to” people or to enable or permit. This definition implies that there is an authority that permits or empowers the people. The definition contradicts the very essence of empowerment.

To us in community health development work, people have to own the issues. They acknowledge that they are in a disempowering social environmental context. They make a critical analysis of their context and resolve that they will do something about their disempowering context.

Medical students may start by identifying what their issues are, for instance, the astronomical tuition fees or a market-driven, commercial medical education or the disconnect between understanding the pathophysiology of the stroke and myocardial infarction and the reality of the coal-fired power plant in the locality or corporate food control that increases the vulnerability to oxidative stress.

Now, in instances where the medical students are not directly affected by the issues, how can they be authentic bearers? Most of the medical students come from the middle class families, bringing with them their middle class biases and blinders. How indeed, can they be owners of these issues not affecting them? When one is in genuine solidarity with the authentic bearers, he or she becomes an authentic issue bearer. As an authentic issue-bearer one needs to analyze the issues from the standpoint of the marginalized or those in a disempowering context.

One example I can give you is the Lumad (Indigenous People of Mindanao) issue. In the past few years, the Lumad killings have been a very serious issue. How does this issue become an issue for medical students? Their ancestral lands have been target for mining. Mining, whose contribution to economy is only 0.91% of the Gross Domestic Product, creates health problems and has resulted to 50 dead rivers all over the country. Try to imagine the impact of this to health of the Lumads and other people and to the biodiversity. The displacement of the Lumads creates health problems for they tend to be temporarily sheltered in evacuation centers not properly equipped and lacking facilities such as toilets, and food supply is inadequte.

The IDPs (Internally Displaced People) become vulnerable to epidemics such as measles. They become vulnerable also to acute gastroenteritis and respiratory infections. Some students may become involved in addressing the health needs of these people. Eventually, they become authentic issue bearers, themselves. Especially if their response is beyond addressing the practical needs. They may decide to be one with Lumads by trying to address the strategic issue of being free from development aggression or to reclaim their schools whose existence has been threatened.

Do you know that Lumads have been deceived into signing a document being recipients of the 4Ps or Pantawid Pamilyang Pilipino Program only to find out that they were made to sign a Free, Prior and Informed Consent, or a document to allow the environmentally-critical project to operate in their areas? This is one of the realities why they have established schools and want to be educated. They were assisted by NGOs because they are not a priority for the government.

We, as medical students and health professionals, cannot impose our own analysis based on our own biases and perceptions of the Lumads. Their analysis becomes our own, based on CRITICAL evaluation and acceptance of an issue.

Message 2: Community Empowerment is people gaining full control over their own lives.

Community may mean people within a shared geographical location but it may also mean people with shared identities or shared interests or shared issues. The implication of this for the medical students as a community is that the school can only provide an enabling environment. The school authorities can only facilitate or catalyze or walk the students through in acquiring power or at the very least, allow and tolerate it. Take note, too, that it is not enough for the students to participate, or get involved or engage in issues. You, as students, should re-negotiate power. This is how you gain control over your own lives.

The school cannot empower the students as if power is something to be doled out. There are instances when the school authorities become a stumbling block to student empowerment. Let me share my own experience of how I achieve faculty empowerment. There were times when my efforts toward providing a real-world learning opportunity for my students in Community Medicine were put into question. I would have given up, if only to simplify things inside this institution, but I was thinking Primary Health Care. I was thinking DMSF vision. I was thinking five-star physician. I had to struggle my ideas out and I asserted for my discourse space on why my students had to be assigned to the communities that may be impacted by the coal-fired power plant in Davao City. After delivering my scholarly presentation and demonstrating to the authorities some models of medical schools doing researches and genuinely critically-engaged in the climate change and the coal power issues, they gave me a go signal.

Our health care models have evolved towards engaged citizenship model. If we are looking at the people-managed models, you will see people gaining full control over their own lives. The tactical needs are addressed (for instance, medicines and vaccines during emergencies). But then we want the community to be pulled out from the dependent context. They have strategic needs (the need to be free from, say development aggression in the case of mining communities, or access to their own ancestral lands) and definitely the methodologies entail more than just health services. This is people gaining full control over their own lives. The social model (of the 1970s and 1980s) , and engaged citizenship model (1990s up to present) will succeed if inputs from the affected communities are considered and if people manage their own development.

Medical students should represent themselves. I have provided an opportunity for students to introduce some changes. One example was during the Yolanda typhoon in Tacloban. The school sent a group of ComMed students through an international organization escorted by the military. The students wanted to see another model which was citizen-led, and without the military escorts. The security issue was addressed because it was a 200-volunteer team and the main mission was only five days to prevent volunteers from getting sick. I encouraged the students to formulate the activity proposal because these were ideas conceived by them and not an initiative by the school. They formulated the Consent Forms and also the Release of Liability Forms. That was, however, disapproved for security reasons based on the biases of the authorities despite the security protocols presented by them. But the students learned new skills in negotiating power.

The road to medical student empowerment is not an easy one for both the students and the student advocates. I feel lucky that in this institution we have a fairly discursive democracy.

The trick there is that, every time I introduce something new, especially in the curriculum or in the learning strategy, I always try to benchmark with other medical schools. It is easier for school authorities to accept if it has been done before. While the social context of the communities should have been the rallying point, I had to spice it up with model academes. Trailblazing is still a challenge for most medical schools.

Message 3: Critical Analysis is crucial to Community Empowerment.

Re-negotiating power is dangerous without critical analysis. Student empowerment requires the students to identify their own problems, the driving forces leading to the each problem, and dissect the disempowering context that exists around the lives of the medical students. There are effective tools for analysis. The Problem Tree, which we utilize in Community Diagnosis, has been effectively used by marginalized groups like prostituted women, peasant farmers and indigenous people.

To understand what Critical Analysis is, let me introduce to you the Levels of Awareness by Paulo Freire. Friere was a Brazilian educator born of middle class parents. He is known for profound theories on education, especially adult literacy. He was one of those who pioneered Transformative Education which I have encountered being applied on grassroots education in the 1980s.

Going back to the Levels of Awareness or Consciousness, Freire mentioned of the three levels of awareness but in the book Helping Health Workers Learn by David Werner, the fourth level which is Fanatical Awareness, was included.

  1. MAGICAL CONSCIOUSNESS: People tend to be fatalistic, passive, silent and docile. They do not question the injustices around them. They see themselves as defenseless. They submit themselves to the dominant force. They have no analysis of the contradictions outside them.
  2. NAIVE CONSCIOUSNESS: People are aware of their problems of injustices but they do not make connections with the world outside. They individualize their problems and see them as personal accidents. When they acquire power they become the mirror image of their oppressors.
  3. CRITICAL CONSCIOUSNESS: People stop looking at their problem and make connections with the structural problems outside them that cause their marginalization. They stop seeing the problems as mere personal or individual accidents. Critical consciousness involves making connections with the socio-economic, political and cultural contradictions in society. It means looking at reality and recognizing such contradictions as a fact.
  4. FANATICAL CONSCIOUSNESS: People who bring their consciousness to the level of fanaticism. And do not connect their problems with structural problems. They tend to blame the victim/survivors for the problems. They simply refuse to listen to other people. Extremism and social prejudice are examples of fanatical consciousness. Their general attitude is that their adversaries are always wrong and they will never be wrong.

Among these four levels, it is Critical Awareness that is important to genuine empowerment. Critical analysis, seeks to understand the interplay of the societal structures and also connects the local scenario with the global scenario. The 1978 Declaration of Alma Ata emphasizes the relationships and hence the health solutions are not only a matter of technologies. Community health development also seeks to address the social structures that underpin health. Communication is vital. Discussions and debates are facilitated to ensure a discursive democracy and a higher level of critical thinking.

Colleagues, I have so many stories from the grassroots. I encourage you to listen to people’s stories because you cannot depend totally on the dominant media to educate you. Among the conscienticized or critically aware media people, I heard of the term “subjugated knowledge” and worse, “programmed ignorance.” Stories are told according to the bias of dominant entities.

To understand “Subjugated Knowledge” or “Programmed Ignorance” I will show you these images. This was in 2008. These were Moro children killed as a result of direct assault against the civilians as part of the implementation of the “All Out War” Policy in Mindanao. I received this information through an email blast from people in the field. Our response was a Fact-finding Mission. I listened to the accounts of the survivors and the stories still make me cry up to the present. This would have been labeled as an act of terrorism if this were done by the enemies of the government. As with our previous Fact-finding report, we recommended for an end of the All Out War in Mindanao to Congress. If we did not gather stories from the people, themselves, we would also have been manipulated for programmed ignorance. If we want to be part of empowerment, try listening to people’s real stories.

Recently, the hospital equipped by Doctors Without Borders (Medecins sans Frontieres or MSF) in Kunduz, Afghanistan was bombed four times by the US Military. If this were done by the enemies of the US, this would have been labeled as an act of terrorism by the dominant media.

  1. Empowerment is not neutral, neither is medical education.

I want you to take a look at this image. This man was commencement speaker of Emory University School of Medicine in 2014. This man is Hon. John Lewis, congressman and civil rights hero. He was arrested 14 times for his civil rights work. What does this tell you of Emory University School of Medicine? The institution has a program for Climate Change. It is also strong on Human Rights. Obviously they are on the side of the people. They are not neutral.

I mentioned earlier about the Transformative Education applied at the grassroots level. My personal memory is from way back 1980s. I was happy that the term Transformative Education got into the mainstream medical academe when I attended a CHED (Commission on Higher Education) conference in Manila. My happiness, however, turned into disappointment when I noticed that what we had, as introduced by CHED, was reduced to mere functional outcomes rather than the originally intended goal of Transformative Education which is to liberate and transform society. Transformative Education is not neutral.

I am proud of APMC for their support of the Morong 43 Health Workers who were illegally arrested and tortured in 2010. This is not neutrality. Taking a stand has a transformative outcome. Taking action is one of the most effective ways to educate the public and the medical students. This is education through real life scenario.

The reality of Neoliberalism (Globalization) is shaping everything that is happening around us. Neoliberalism is not an innocent philosophy. It was the reality of social inequities under neoliberalism that all nations gathered to formulate the Alma Ata Declaration of 1978 and gave birth to the Primary Health Care Concept. This is not neutrality. The Philippine government was a signatory.

It is for neoliberalism that we are being dictated to implement the privatization of health care or even medical education. In neoliberalism everything is market. We are not citizens but market for health services. Public services have to subscribe to private entities and pay for the services. Foreign entities invest in our health services. Our government becomes a partner because they are made to assume the investment risk. The profit is privatized. In other words, foreign investors keep huge profits. The other role of the government is that of a market agent. Since health is not a priority because the neoliberal system does not allow the government to spend for social services, the citizens have to contend with limited health services. How should our medical education respond to this reality?

Arnold Seymour Relman (1924 – 2014), Harvard professor of Medicine and former editor-in-chief of New England Journal of Medicine, said “The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research. The academic institutions of this country are allowing themselves to be the paid agents of the pharmaceutical industry. I think it is disgraceful.”

We decide which track we go. There is no neutral ground – for neutrality means no change, no social transformation. Neutrality means being on the side of the oppressor, the powerful and the dominant. Medical institutions can decide whom their medical education should serve. The institution may serve the entity that represents the “Oppressor” or the dominant, or those with economic power to buy the services of the graduates. It may also decide to produce graduates that serve the “Oppressed,” or the underserved, or the poor.

Message 5. Physicians, as well as medical students, can be as empowered as being the game-changers or even heroes.

There have been instances when physicians have contributed so much as to influence the end to even the gravest threat to human lives. For instance, the physicians all over the world forged solidarity to help end the Cold War. The Cold War (1947-1991) was the nuclear arms race between US (with its allies in NATO) and Russia (with its allies in Warsaw Pact). If this did not stop, our country would have been among the first to be devastated because we hosted the nuclear arms of the US. In 1985, the International Physicians for the Prevention of Nuclear Warfare (IPPNW) was Nobel Peace Awardee. They repositioned the Cold War as a public health issue. Davao City’s contribution was an ordinance declaring the city nuclear-free. The medical students were part of IPPNW.

In Ontario, the researches of physicians that translated into a political stand by the Ontario Medical Association to de-smog the region resulted in the closure of coal-fired power plants in 2014. Their research demonstrated that the air pollution from the coal-fired power plant resulted to 1900 deaths/year that cost the economy $10 billion/annually. After they have shut down the last coal plant, they are targeting another dirty energy, the nuclear power plants. There are many more success stories whereby physicians demonstrated heroism rather than choose the path of cooption with the oppressor entities.

We can be game-changers in our locality. I am proud to say that Davao City already had the Women Development Code long before the Reproductive Health Law was passed. The women’s movement also dealt with the flaws of the RH Law at the LGU level. Our critique of RH Law was that environmental health and climate change were blind spots in the discourse. We adopted a resolution through the Integrated Gender Development Division in 2013 to integrate climate change as part of Reproductive Health issue to be addressed. We also passed an anti-discrimination ordinance in 2012 and we are hoping that this should not deprive the children of the “Age and Development-Appropriate Sex and Sexuality Education.”

We must remember that children under 15 years are vulnerable to abuse, incest and other forms of violence yet they are excluded under the RH Law. The Davaoeňas also saw the reality of privatization of health care that may also take shape and may negate the original intention of making RH services available to the marginalized women. The women’s movement made a stand against privatization. Mayor Rodrigo Duterte is against the principle but has no definite action yet.

This is how the critically engaged citizenship of the women of Davao City has made a lot of things easier for the Obstetrics-Gynecology practitioners. Of course the doctors share the victory because they supported the struggle through health services. The grassroots women flexed their collective muscles and their debate space were the streets while the representatives were in the council lobbying for women’s health.

Did you notice that private hospitals of Davao City have packages for caesarian sections, hysterectomies, curettage and tubal ligations? We, at the Brokenshire Hospital started that. Fresh from our residency training program we figured out how we can make our services accessible. We also had allies from among our mentors. We also took into consideration the corporate vision of our health institution. We saw our hospital as a sinking boat and we had to save it to keep everybody afloat.

We received a letter from our medical society warning us that our decision may compromise the economics of the practitioners. We just continued with the packages and it did not make us poor. In fact the packages created what is known as “Beehive Effect.” We grow the bees for the honey. But the other activities of the bees like cross-pollination give more crops and economic gains. The fact that all private hospitals now have institution-based packages for a number of surgical procedures is a manifestation of success. We also created programs for cataract packages and surgeries for cleft lip and palate surgeries by forging partnerships with various NGOs. This clearly demonstrated that the once empowered medical students in us also made for empowered physicians.

When one makes changes based on genuine social change, it is one that entails the so-called “conflictual” model. If you see violence when one starts the “conflictual model,” it is not on the side who only wanted change. You only challenge the structures that cause the disempowerment of the people like development aggression against the Lumads, the stigmatization of people living with HIV/AIDS, or feminization of migration. We need to confront and act on these unjust structures that breed insatiable greed or we lose our humanity.

Thank you very much for this tremendous opportunity to share. I dream of seeing you on the same side one day, the side of EMPOWERMENT.

Once again this has a disclaimer. All the opinions expressed do not represent any institution I belong to. It represents the stand of the people’s movement which owns me. Maraming Salamat po ulit.

(Dr Jean Lindo is an anesthesiologist and a community medicine practitioner. As Community Medicine practitioner she has done Health and Human Rights work for three decades. She is chair of Gabriela Southern Mindanao, the largest grassroots women’s organization in Southern Mindanao, and co-chair of Panalipdan! Mindanao, the biggest grassroots-based environment group in Mindanao. She is currently faculty member of Department Community Medicine of the Davao Medical School Foundation).

Community Empowerment. 7th Global Conference on Health Promotion: Track themes.
Jaime Z Galvez-Tan. Health in the Hands of the People. 2013. JZGALVEZTAN Health Associates.
Leahy, Derek. Ontario’s Electricity is Officially Coal Free. DeSmog Canada. 2014.
Werner, David. Empowerment and Health. Contact. Christian Medical Commission, World Council of Churches. Switzerland. 1988.