MANILA, Philippines?The rain on a health workers? training workshop in Morong, Rizal, and the arrest of 43 health professionals and workers continue to be front-page news.

The other night on the TV program ?Crossroads,? Lt. Col. Noel Detoyato, spokesperson of the Armed Forces? 2nd Infantry Division, noted that the workshop participants generally had low educational attainment, and cited this as one reason why they were suspected as subversives. Detoyato even enumerated the participants? educational profile: 5 had elementary education, 4 were elementary graduates, 7 had high school education, 12 were high school graduates, 5 had college education and 4 were college graduates. He then mentioned that one of the participants had only finished first grade, and that this person was wanted for murder.

The colonel?s revelations reflect society?s prejudice against people who have had little formal education. ?Uneducated? means ignorant, with connotations of the criminal and the subversive. Moreover, in this case of the health workers, there is the insinuation that the ?uneducated? (read the poor) couldn?t become health workers.

Yet for nearly half a century now, there has been a quiet global revolution going on, where people with minimal education have become excellent community health workers. In the Philippines, such training dates back to the early 1970s, when Filipino health professionals put up community-based health programs (CBHPs) with community health worker (CW) training as its centerpiece.

The Filipino CBHPs drew inspiration from China?s health care system, one which built upwards from the communes and villages. A hallmark of the Chinese system was the training of barefoot doctors, so-called because many had minimal formal education. Yet, with training of six months to a year the barefoot doctors could handle many of the most important health needs in their villages. Some eventually went on to medical school. One of them, Chen Zhu, rose through the ranks to become minister of health.

The Chinese system of barefoot doctors caught the interest of governments and NGOs throughout the world. The John Fogarty Center in the United States translated a hefty Chinese book, ?The Barefoot Doctors Manual,? into English and published it, with many copies sold in American bookstores. I sometimes suspect it ended up as family health manuals with all the information it carried.

Promoting health

In many Latin American countries, there were programs for promotores de salud (health promoters). I like the term with its emphasis on preventive health rather than the curative. As in China, the promotores de salud were often villagers with very little formal education.

In Mexico, an American biologist, David Werner, began his own primary health care program and produced ?Donde no Hay Doctor,? which included his own wonderful illustrations of peasants performing all kinds of medical procedures. The manual was translated into many languages. Locally, the Philippine Charity Sweepstakes Office printed ?Where There is No Doctor? as well as a Tagalog translation, ?Kung Saan Walang Doktor.? (I still remember that one of David?s illustrations had to be modified for the Philippine version of his book: an uncircumcised penis in the book, following the Mexican norm, had to be redrawn according to Filipino standards.)

The Filipino CBHPs were handled by NGOs, many affiliated with Roman Catholic and Protestant social action programs and serving very remote communities. I was part of those CBHPs and participated in many of the training workshops. Yes, those being trained were often barely literate, but I learned, early enough, that the low levels of literacy could became an advantage. Because they could barely read or write, the health workers learned mainly by attentive watching and apprenticeship.

In 1978 the World Health Organization endorsed primary health care as a global strategy with the ambitious target: ?Health for All By the Year 2000.? Many governments, including our own, adopted the rhetoric and at one point the Department of Health claimed that it had trained some 350,000 barangay health workers (BHWs) throughout the country. I also participated in some of those training sessions. They tended to be quite basic, with large groups of BHWs herded into gyms and community centers for two to three days of lectures on first aid and basic health care.

The NGOs, in contrast, had longer and much more intensive training with additional workshops for more advanced skills. Following the spirit of the Alma Ata declaration, health workers also learned to organize and mobilize communities for health. That organizing component was what created tension with paranoid military and government officials, who couldn?t understand that the ?public? in ?public health? means social mobilization, for example, mothers learning where the health centers are and what services are available.

When China initiated economic drives and its modernization campaign, it abolished the communes, together with the barefoot doctor training. The allegory they used was that of putting shoes on the barefoot doctors. But almost 30 years of an increasingly commercialized health care system has brought many problems and there is talk about restoring elements of the primary health care system.

Caregivers

In the Philippines, the NGO CBHPs continued, health workers remaining active even in places where CBHPs had been phased out. A few years ago while lecturing to a group of municipal health officers, one of them told me some of her best health workers were those trained by our CBHPs more than 20 years earlier.

Over the last decade, we have seen another phenomenon: that of caregivers? training, a six-month course with many similarities to the barefoot doctors or community health workers? curriculum. Sadly, the main goal of such training programs is to produce Filipino caregivers for export.

We should look into formalizing the caregiver curriculum as a vocational course, with a shift in emphasis toward meeting local needs. They could work with families having special medical needs, or with communities, clinics, hospitals, retirement villages, and, let?s not forget, military camps.

Call them barefoot doctors, CHWs, BHWs, or caregivers, the point is to train more people to raise the country?s health literacy levels, deliver health services and, most importantly, organize people to take care of their own health needs.

On the ANC program, Detoyato also mentioned that one of the arrested health workers was a ?retired teacher,? again as if to prove the health workers were spurious. Really now, age, sex, educational attainment, religion and yes, even ideological affiliation, should never disqualify someone from becoming a health worker. The only eligibility for such health workers should be a commitment to serve.