PHM-Exch> A tribute to David

[Claudio Schuftan]

*David Sanders, pioneer of Health for All – as remembered by David Werner*



When David Sanders died suddenly of a heart attack on August 30, 2019, it
was a great loss. But his many friends and colleagues around the world can
take heart that his passing did not leave a vacuum. To the contrary, David
left a legion of fellow travelers around the world who, thanks to him, are
today more strongly committed, better prepared, and have a greater sense of
solidarity to continue the uphill struggle for health. After his passing,
the huge outpouring of appreciation for his exemplary contribution
worldwide makes it clear that his contagious spirit, boundless energy, and
unflinching honesty in the face of power lives on in the vast spectrum of
people – from community health workers to international movement organizers
– who had the good fortune to know him.



Indeed, so many fine tributes have already been circulated in praise of
David Sanders that it seems there is little more to add. Therefore, I will
focus on my own personal interaction with him,  which began over 40 years
ago.



I first met David in the late 1970s in London, where he was working for
Oxfam. At that time, David was in exile from his homeland in Rhodesia,
where he’d been a strong proponent for that country’s independence from
Great Britain’s colonial rule. As a pediatrician in that land, David had an
early exposure to the devastating impact that entrenched inequalities of
power had on the wellness of the subservient population. Thus, in the
pursuit of health and social justice, he’d become an avid activist in the
grassroots movement for Rhodesia’s independence. Faced with threats to his
life, he went into exile to the UK, where he continued his advocacy for
Rhodesia’s independence.



On one of my trips to London during that time, to present a paper on
“Health Care and Human Dignity”, David Sanders invited me to his circle at
Oxfam. He’d used my books *Where There Is No Doctor *and *Helping Heath
Workers Learn* in his community health promotion in Rhodesia, and in our
Hesperian newsletters he’d read about Project Piaxtla, the villager-run
health program in western Mexico I’d helped start. He told me of his goal,
once Rhodesia was liberated, of helping the newly independent country set
up a national health program based on Comprehensive Primary Health Care, in
which local community health workers – chosen for their commitment to the
common good – would be agents of change in the promotion of a more
equitable, just, and thereby healthier society.



No sooner did Rhodesia – now Zimbabwe – in May 1990, win its independence
from the UK, than David Sanders at once returned to his homeland, where he
was recruited to play a key role in forming the new Ministry of Health.



In that early realm of independence, David Sanders invited me to visit
Zimbabwe, both to witness the new, people-centered mobilization that was
underway, and to share some of my experiences of community-based health
promotion in Mexico and elsewhere.



Part of David’s motive in bringing me to Zimbabwe was for me to give
presentations and exchange observations with key honchos in the new health
ministry, some of whom were still wedded to the conventional model of
Western (i.e., colonial) medicine, with its hierarchical pecking order and
its focus on sickness rather than health.



For a while, David and his cohorts made good progress with the new, more
holistic, community-centered initiative, along the lines heralded in Alma
Ata as “Primary Health Care”. The nation’s top decision makers – still
imbued with the revolutionary spirit of newly won independence-- made space
for this more democratic, people-empowering approach to health care. But
sadly, as so often seems to happen in human history, those who had been
heroes in the fight for liberation, once they rose to power, gradually
became oppressors themselves. As wealth again began to concentrate at the
top and the state became more authoritarian, priorities shifted. The
egalitarian, more empowering community-based approach to health promotion
advanced by David and his colleagues fell out of favor with the controlling
class – especially with the conventional medical establishment. His
detractors began to hit below the belt, lambasting David as a “white
colonial” who was trying to impose second-class services on what he viewed
deep-down as second-class people.



This was painful for David who was deeply committed to health and fair
treatment for all. In time the barriers to advancing universal primary
health care in Zimbabwe became so great that David decided to move to South
Africa. At that time South Africa was still under apartheid rule, with a
huge gap in wealth and health between the white elite and the black
majority. But it was not without hope for change. There was a strong and
growing resistance led by the African National Congress (ANC) and others.
Even the medical establishment itself was divided. After the mainstream
Medical Association of South African (MASA) defended a doctor who had
overseen the torture of Steven Biku, an outspoken leader of the Black
Consciousness Movement, a portion of MASA’s members split off in protest.
They then formed NAMDA (National Medical and Dental Association), which
took a united stand for racial equality. NAMDA also introduced a network of
community-based health care in shantytowns, providing training and backup
for local, relatively unschooled, but socially committed health promoters.



As part of the coordinated effort to promote international awareness and
solidarity in support the South African struggle against apartheid, David
Sanders and his colleague reached out to the global health community. Among
other actions, David arranged for NAMDA to invite me to visit the
mushrooming shantytowns outside Johannesburg and to engage in an
educational exchange with its field organizers. While there, we shared
experiences and methods for implementing CBHC (community-based health care)
in marginalized communities, and encouraging people to analyze the social
and physical determinants of health and to work together to improve their
situation.



This exchange – instigated in large part by David – took place (I believe)
in 1992. The growing anti-apartheid tide was then being countered by a
ruthless escalation of repression, curfews, and arrests of activists. Many
in the struggle grew discouraged. But David and other leaders of NAMDA were
confident that the racist regime was planting seeds of its own demise. Its
draconian clampdown on protest only triggered greater resistance. … And
sure enough, in an attempt by the ruling class to quell the rising storm,
Prime Minister F.W. de Klerk agreed to hold South Africa’s first all-race,
democratic election. In May 1994, Nelson Mandela – who had been freed after
27 years in prison – became South Africa’s first president of the nation’s
post-apartheid era.



Much of the more recent history of David’s indefatigable role in promoting
health-for-all and social justice – in South Africa and worldwide –  is
well known to his contemporary friends and colleagues. Many have given
tribute to his on-the-ground research and service-oriented training of
students, which he spearheaded for decades at the University of the Western
Cape. I will therefore focus here only a few more of my own undertakings
with David, with which some of his younger colleagues and admirers may be
less than familiar.



Everyone is aware of the seminal role that David has played in the
formation and ongoing pursuits of the People’s Health Movement (PHM). But
fewer may be familiar with his previous key role in the International
People’s Health Council (IPHC), which in many ways was the precursor of the
PHM.



The International People’s Health Council was launched in    Managua,
Nicaragua, in December 1991, at the closure of a small international
symposium on “Health Care in Societies in Transition”. The symposium and
the IPHC that grew out of it were conceived and organized by several of the
same pioneers in Primary Health Care who, nine years later, in 2000, would
be instrumental in midwifing the first global People’s Health Assembly
(PHA) and the People’s Health Movement that grew out of it. These key
players in launching both the IPHC and the PHM included Zafrullah Chowdhury
(Bangladesh), Mira Shiva (India), David Sanders (South Africa), Maria
Zuniga (Nicaragua), and myself. The idea for the symposium had initially
been conceived several years before, during the Sandinistas’ heyday in
Nicaragua, when revolutionaries, backed by a diverse workforce of *brigadistas
de salud *(community health brigadiers), had overthrown the tyrannical
Somoza government and set up a people’s republic. In a few short years, the
fledgling government – backed by strong community involvement – had
achieved spectacular improvements in health. Inspired by this success
story, our motley group of health activists decided to hold the transitions
seminar in Managua. We saw Nicaragua as a shining example of a society in
transition to achieving better health. Ironically, however, we delayed too
long in getting our symposium off the ground. In 1990, after years of
ceaseless attacks by the US-financed “Contras” and of infiltration by the
CIA, the weary population voted the Sandinistas out of power and voted in a
coalition government that was puppet to US imperial interests. Rapidly the
people-supportive agenda of the Sandinistas was rolled back, the gap
between the rich and poor grew wider, and the population’s health once
again began to deteriorate. Sadly, Nicaragua was not alone in this pattern.
Similar reversals in democratic process and in the health and welfare of
the people were then taking place in many countries, spurred by economic
globalization with its structural adjustment mandates and so-called “free
trade” agreements. So our transitions seminar, initially planned to learn
from societies transitioning to *better* health, ended up discussing
transitions that were endangering and worsening the health of societies.
Our seminar’s challenge was to explore possibilities for reversing this
retrograde process. (All this is written about in David Sanders and my
book, *Questioning the Solution – *see below.)



We felt our seminar’s analysis of the current social and political
determinants of health, and possible action for coping with them, were
important enough they should be recorded and shared. So Maria and I and
others put together a booklet of the proceedings, which we titled *Health
Care in Societies in Transition *(published by HealthWrights in English and
by CISAS in Spanish). We also thought the dialogue we had begun should be
continued, with more health activists participating. Hence we launched the
IPHC, which grew in size and had subsequent international meetings. The
most notable of these events took place in Palestine and in South Africa –
the latter adroitly organized by David.



After a few years, PHM – with a much larger cast of players – took over and
expanded the role of the role of the IPHC, whose mission it continued.
David was a wise and dynamic spearhead of both.



David Sanders wrote over 50 groundbreaking papers and several books. His
first book, *The Struggle for Health: Medicine and the politics of
underdevelopment, *published in 1985, was a bombshell. It likely did more
than any other publication to awaken the international health community to
the fact that a population’s health is determined more by the distribution
of power and resources than by health services per se.



Over the years David and I realized we shared similar perspectives on
health and social justice. In the mid-1990s we started writing a book
together, which we eventually titled *Questioning the Solution: The
politics of Primary Health Care and child survival. *I visited Cape Town
and he visited California to complete it. This book is lengthier than *The
Struggle for Health* and contains a lot of examples from Latin America
(most extensively Mexico, Nicaragua, and Cuba). As a case-study, the book
explores in-depth the worldwide promotion of ORS (oral rehydration
solution) for the treatment of diarrhea. (For this reason, with tongue in
cheek, David and I titled the volume *Questioning the Solution. *The idea
for the title was David’s.) Undoubtedly, the vast promotion of
mass-produced packets of ORS has substantially lowered child mortality from
diarrhea. Yet, as *Questioning the Solution* points out, other solutions –
namely homemade cereal-based drinks – may have saved even more children’s
lives – and done so less expensively, more quickly, and more effectively,
with less dependence on a distantly-produced commercial product that may
not always be available. Yet the economic leverage by Big Pharma on WHO and
UNICEF to promote their commercially-produced ORS packets (which rapidly
became a multi-million dollar business) stacked the deck in their favor. So
it was that the less ideal but more profit-generating option has been
universally promoted, sidelining less costly, more quickly available, and
potentially more effective home solutions. The consequences of this
grand-slam marketeering may have cost millions of children’s lives – and
still does.



David felt very strongly about this exploitation of children’s health and
the myriad other ways in which Big Pharma, Big Sugar, Big Oil, Big Ag, Big
Water, Big Media, and other corporate superpowers put profit before people
– and before sustainable life on the planet.



Sadly, our companion David Sanders is no longer with us in person. But his
struggle for “health for all” lives on in the minds and hands of the
countless friends and students and activists whose lives he so deeply
touched. We all owe it to David to indefatigably keep his action, his
vision, and his passion – and his wry sense of humor – alive.
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