INTERNATIONAL ACHIEVEMENT AWARD
FLORENCE NIGHTINGALE INTERNATIONAL FOUNDATION LUNCHEON
JUNE 30, 1999, LONDON, U.K.
It is a tremendous honour for me to be here today to receive the Florence Nightingale International Foundation’s International Achievement Award as well as the privilege of addressing this distinguished audience to share with you some of the experiences I have had during my international health career. Particularly, I welcome the opportunity to make some recommendations to the nursing leaders in this room on how we can improve and strengthen the role of nurses around the world in achieving Health for All.
I have been fortunate during my career to work both in developing countries as well as in public health in my own country. In both cases, there are huge groups of people who are particularly vulnerable to poor health because of their grinding poverty.. As a result, the main message I want to leave with you today is that to really improve the health of a people, as nurses we must be more than health service providers, we must be political activists and agents of change.
To illustrate this, I would like to take you on a quick voyage through some of the major events and experiences which have influenced my life’s work and commitment over the past three decades. Don’t worry as proof of my own small contribution during these 30 years to the large picture of things, I can easily do this in 25 minutes!
THE THREE DECADES VOYAGE
1st Decade: India
Little did I know when I set off for India in August of 1968 that I was taking the first step in what was to become a long-term commitment to international development. Like many young people of the 60’s I felt more a sense of adventure than commitment. My family was somewhat taken aback by my choice of career and gave me three months before I returned to Canada. Of course, born with a healthy degree of Scottish stubbornness, that readily ensured that I was determined to stick it out!
India, that magnificent subcontinent of contradictions, laid the basis for my appreciation of what nurses could do to improve a nation’s health status as well as a deep and lasting understanding of how difficult that work could be. India at that time already had a vast network of Primary Health Care services covering the whole country. Many lessons were being developed there which would later inform the WHO and UNICEF in l978 in the development of the Declaration of Alma Ata.
However, even an excellent 5-Year National Health Plan on paper in the Ministry of Health, can look very different in a village health centre. For those of you who haven’t been there, can you imagine that rural clinic. The Clinic may just be one or two rooms. Most likely it does not have electricity. The staff is made up of 1-2 auxiliary nurse midwives and perhaps one other multi-purpose health worker. The Centre is probably about 10 miles from the next level of service where there might be a doctor, but probably not. The auxiliary nurse midwives are: young, scared, lonely, probably having just recently graduated, (after all, these are entry level positions and not exactly sought after by the more experienced nurses), they are working in a strange village, (probably one that is wondering why these young women are allowed to live away from their families and, therefore, if their moral reputation is not in question), they may even have to sleep in the health centre because housing has not been provided. On top of that, they have to deal with all the health problems that come to the health centre’s door. That means: severely malnourished children, complicated births, all manner of infections from malaria to, dare I date myself, smallpox. Very often she has very little at her disposal in terms of medications or supplies. In addition, supervision is much more likely to be disciplinary rather than enabling or supportive.
However, lest you believe that all was negative or impossible, you also have to imagine the tremendous courage and ability of many of these young women to provide service to the communities where they served. They did it a huge personal cost and with difficulty. They did deal with the most common health problems and largely because of them,
statistics have shown us that maternal and child mortality and morbidity in India has fallen.
Two major learnings:
• without a large and well prepared front line nursing cadre, it is impossible to deliver health services to the largest number of people. This personnel is not necessarily always the professional nurse, but often auxiliary personnel;
• building the PHC centre and staffing them was the easy part, making them effective was the major challenge. As always, we underestimate the importance of the human resources in making grand plans work.
THE 2ND DECADE CENTRAL AMERICA
During this time I worked in Central America, which could not have been more different from India. This was a time of tremendous political upheaval in almost all of Latin America and where, with the notable exception of Costa Rica which had invested in social services instead of military, many governments were openly or clandestinely at war with their own people. PHC services did not extend down into community very far, and even in the few cases where they might have existed, the very poor people of the community did not have much confidence in government’s sincerity for their welfare. In addition, because Latin America has traditionally produced more doctors than nurses, there were few human resources to deploy to rural health centres.
However, in this environment, a different phenomena was occurring. Communities were organizing their own health services. Modeling themselves on the experience of the Chinese barefoot doctors, community health promoters were very effectively dealing with the main health problems in their community, and even more importantly, dealing with the root causes of those health problems. The health promoter became an agent of change in their community. This movement received moral, technical and economic support from the progressive wing of the Catholic Church, acting under the Vatican II instruction of “An Option for the Poor”. Other churches also participated, and some of you may have heard about the Berhorst Clinic in Guatemala where, with the notable exception of Dr. Berhorst himself, the entire staff of the hospital and the community outreach programmes was community health workers. The effectiveness of the CHP as community leader was unfortunately recognized by the military government, and these people became targets of the brutal repression of that time.
At the same time as social movements were developing thought Latin America an equally important, and very significant, event was happening at a global level. In 1978, the World Health Organization and UNICEF held a Conference which resulted in the preparation of the Declaration of Alma Ata with its Global Goal of Health for All by Year 2000. This landmark Declaration recognized, for the very first time ever, that citizens of every country had a right to access to health services, and that the State had a responsibility to provide for that access. A great nurse leader, who deserves recognition at this moment, was the late Dame Nita Barrow from Barbados, at that time the head of the Christian Medical Commission of the World Council of Churches, and for me, a teacher, mentor and role model. She and other health workers were committed to the concept of social justice for the poor and the right of access to health services. They were the principal movers in the creation of the Declaration of Alma Ata. We have much to be grateful to them for what has been achieved in the past 22 years. The WHO and UNICEF played a key and significant role in legitimizing and integrating the experiences taking place in so many parts of the world. Without that legitimization, we could not have achieved an international consensus on health as a social justice issue nor the implementation of Primary Health Care as the strategy to achieve it.
The optimism of the time led the world’s health leaders to believe that the Goal of Health for All by Year 2000 could be achieved by that date through the global strategy of the development of primary health care services in every country. This would require a commitment from government to allocate health resources to the development of a nation-wide system of health centres and human resources which could work outside of the confines of hospital services. There is still much debate about whether or not the Goal of HFA/2000 has been achieved. The pessimists point to the health problems which still exist in most parts of the developing world, whereas the optimists point to the gains in health status which have been made almost everywhere. I know of no developing country which has not undergone major reorientation of their health services in a valiant reach towards that goal. The right steps have been made in the right directions.
If we had a limitation in that Goal, it was in thinking that the creation of primary health services would, in themselves, produce spectacular improvements in health status. We failed to take into consideration the surrounding issues of poverty and to understand the greater potential of a community health centre and the staff who worked there. We have not given the primary health care staff the required community development skills to make an even larger impact.
Another Two Major Learnings
• there are tremendous strengths already existing in each community which can have a positive impact on improving health. Indeed, if these are not taken into consideration, the health services could actually disempower a community. I have found it interesting that the ICN Vision recognizes this on an individual patient level. My experience in Central America that taught me that this could be expanded to a community level. Community health promoters (volunteers) with basic training could deal with 80% of health problems and more importantly, because of their close link to the community they are better placed to deal with root causes and social / cultural barriers to changes in health behaviours. The role of the nurse in this situation is that of a trainer and facilitator rather than primarily a service provider.
• The second lesson was the importance of policy work at an international level. There is no doubt in my mind that the Declaration of Alma Ata and promotion of Primary Health Care is the most defining international health policy statement for social justice in my lifetime if not in this Century. As well it gave us a practical methodology for achieving it.
3.THE THIRD DECADE: CANADA AND AFRICA
In many ways this has been the integrating decade for me and has defined my work with the Canadian Public Health Association. The 22 years since the Declaration of Alma Ata have seen political obstacles and economic difficulties which were not foreseen in 1978 when the Declaration was written. The crushing burden of Third World debt consumes up to 80% of some countries’ GNP, leaving little left for social investment. The Structural Adjustment Policies of the IMF forced governments to reduce public sector funding causing the ridiculous situation of nurses throughout the world losing their jobs and creating a scarcity of nursing personnel. In developing countries this was even more ludicrous because it represented an enormous loss of the investment which had been made in the education of the nurses and the creation of professional jobs for women. There was, and still is, a huge brain drain as human resources flow into countries which still provided jobs. This has been particularly true for Africa. At the same time, deficit-reducing and economic restructuring of the economies of many industrialized countries saw international development assistance stagnate and sometimes even fall.
As the Director of the Canadian Public Health Association’s International Programmes, our international activities have been shaped around support for national strategies to strengthen primary health care services. We have aimed this support at community-level health programmes, human resource development, and advocacy to change policy directions. We are convinced that the weakest point of the health care system remains that point of interface between the health centre and the community.
There is better chance of improving health where health workers move beyond the walls of their health centre to address the underlying causes of poor health, including poverty. Nurses in many countries are doing just that. I was very moved at the recent World Health Assembly’s Award Ceremony in which a nurse from Zambia was recognized for her work in a remote rural area of that country. She was a real agent of change in her community and had, among other health activities, established income generating activities for women and clubs for the teens. I recognize that not all nurses are able to do this kind of work, but more of us must.
In Canada, public health nurses are in the front line working on the streets with the homeless, the mentally ill, youth with problems involving drugs and HIV/AIDS, abused women and children, as well as the working poor. Nurses are also working politically to build coalitions to advocate for policy directions. The current horrendous and increasing social problems should not exist at the end of this Century. They are simply unacceptable.
We are beginning a new Century and Millennium. There is no doubt that we have come a long way in this Century in improving the health of all people everywhere. However, we are beginning to see the limitations of health services as we built them so far, and I believe that we are looking again, as we did at the beginning of this Century, at the social determinants which produce a healthy and productive society. Nurses have to keep their vision on that horizon. Because we are so many, we have the opportunity and responsibility to bring about change. We can do that without losing our traditional role as the caring profession. What would it take? I would suggest the following:
• give nurses the skills to move out of the health centres with confidence to work with the communities they serve (i.e.the Zambian nurse). Strengthen their ability to build on the cultural strengths of communities and the courage to change what is bad and harmful;
• provide nurses and community health workers with a learning environment and supportive supervision;
• enable nurses to take their experience of caring for their patients to relieve suffering and to apply these experiences to bring about systemic changes;
• nursing associations around the world collaborating and sharing experiences and resources; (twinning, and ODA financial support - most donor agencies like nurses!)
• recognition by nurses of the important contributions of auxiliary nursing personnel and community health promoters;
• the greater involvement of nursing personnel in multi-disciplinary, issue oriented organizations such as national public health associations
None of this is very new, and even more importantly, none of it is impossible. However, it requires renewed energy and commitment.
This international Congress has brought together over 4000 nurses representing almost every country of the world. It could be the start of a renewal of international cooperation and joint activism among nursing organizations. Nurses involved in social change for better health could be a major theme for future Congresses and for support and recognition by the Florence Nightingale International Foundation. The exchange of experiences of nurses working to bring about change at local and national level would bring encouragement and practical support to nurses across country borders.
The decision of the Foundation to establish an International Achievement Award takes us in that direction. I am both honoured and humbled by being its first recipient. I know that as the Award becomes better known, there will many more potential recipients, each with a unique experience to teach us.
I would like to thank the ICN/ICNF;
Pay tribute to nursing colleagues from Canada;
Express my gratitude to my own community of family and friends who have helped to shape my views, support and encouraged my career, and to some of them who have travelled here today.
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