In my column the other week, I referenced the case study called “Ang Kuwento ni Rosario” in articulating the injustices that surrounded the death of Baby River, who, although officially a victim of pneumonia, “just like Rosario… might as well have been murdered through the circumstances of her short life.” Such is the resonance of the case to today’s events that my fellow columnist, Dr. Kay Rivera, likewise cited it early in the pandemic to question the factors that led to people dying of COVID-19.
For those interested, the case study itself can easily be searched online. But even those who have encountered the case study may not be familiar with its background, so let me share with you what I have learned about the story behind “Ang Kuwento ni Rosario.”
Curiously, my investigation began in South Africa last year, where, to my surprise, one of the activities we went through as part of a workshop on health inequity was very similar to “Ang Kuwento ni Rosario.” When I asked David Sanders, one of the speakers, about it, he mentioned that the story was inspired by David Werner, his fellow pioneer in the primary health care movement.
Werner, in turn, was a health care reformer who used case studies from his work in Mexico to affirm, in keeping with the Alma-Ata Declaration in 1978, “that health depends on equity.” In “The Story of Chelo,” for instance, he tells the story of a poor man with tuberculosis. After having people read the story, he invites them to identify the “chain of causes” that led to Chelo’s TB and how it devastated his family.
Now for the Philippine connection: As it turned out—and as helpfully recounted to me by Prof. Michael Tan, Dr. Delen dela Paz, Dr. Buching Paterno, and others—Werner actually visited the Philippines in 1981 together with health workers from Central America, and it was during this exchange with people involved in community-based health programs that he shared his approach, which his Filipino counterparts then adapted and modified.
“It was an excellent teaching strategy,” Gerardo Andamo of the Council for Primary Health Care, a health NGO, told me. “We searched for a true-to-life story in an urban poor setting. During that time, a girl named Rosario died of diarrhea as a complication of measles. The underlying antecedent cause is malnutrition. The story of the child’s death further strengthened the community’s decision to participate in the establishment of the health program in the area.”
Andamo ended up writing the case study himself in 1982, but he and his colleagues modified Werner’s approach to account for the complexity of socioeconomic factors. “From a simple chain of causes… we elevated the discussion to become a web of causes all contributing to the futility of the situation and deepened discussion on ill-health and poverty cycle.” (Dr. Dela Paz added that when they went back to the community—Barangay Tañong in Malabon—months later, Rosario’s family had already left the area.)
As the years went by, “Ang Kuwento ni Rosario” proved to be an effective starting point to talk about health as a social and political issue in a way that people can relate to. For instance, Professor Tan used the case study to talk about the need for pharmaceutical reforms in 1986, given the “useless or dangerous” medications Rosario was prescribed with. The finer points of the case have undergone tweaking to accommodate the issues and paradigms of the time—e.g., reproductive health and the devolution of health care system in the 1990s, “social determinants of health” in the 2000s—but the original story has remained unchanged for almost four decades.
I think it is a testament to the self-effacing character of the people in the health movement that nobody really sought credit for the case study all these years; instead, they were happy to leave it as an open source document that people could freely use. This piece is in part a tribute to them and those involved in primary care and community medicine, many of whom have dedicated their lives to imparting the lessons of Rosario to the next generations of health professionals.
But the only way to truly pay tribute to those pioneers—and do justice to the people they wrote for, with, and about, is to carry on their work. Rosario and Baby River may have passed away, but by calling out the violence, structural and real, that surrounded their illnesses, holding the perpetrators to account, and acting on the web of causes that led to their deaths, we can prevent many others from suffering their fate.
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glasco@inquirer.com.ph