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medico
380 friend
circle bulletin
February 2019
The Alma Ata Declaration and Elements for a PHC 2.0
Ritu Priya, Rakhal Gaitonde, Mohit P. Gandhi,
Amitabha Sarkar, Sayan Das, Prachinkumar Ghodajkar
Abstract for a series of three linked equitous, pluralist, context-specific, and or-
articles ganically linked health system, such a health
system is what can contribute to creating a
Based on understandings from histori-
democratic ethos and people’s wellbeing.
cal experience, we believe that an overly
centralised political and economic system It is in this context that we see an inte-
is not the most sustainable or best for grated critical political economy and politics
people’s health and wellbeing, nor is a of knowledge framework as essential to
centralised and monolithic health service understand the health system, as also to
system. It tends to get bureaucratised and create the vision for a futuristic holistic health
a ‘governmentality’ takes over rational and system that ensures HFA. We present our
progressive democratic intentions. This cre- understanding towards such an effort in
ates a mechanistic framework that does not three articles. This first is an analysis of the
organically relate to the marginalised ma- Alma Ata declaration and related docu-
jorities and diversity of communities. ments, also explaining the combined politi-
Thereby it is unable to respond to people’s cal economy and politics of knowledge ap-
urges and sense of wellbeing. At the same proach to HFA. The second article sets out
time we recognise the essential role the the politics of knowledge in health and how
state has to play in contemporary times, as it influences health governance. The third
arbiter and re-distributor of society’s power article presents a vision of health and a
and resources for a democratic and egali- healthcare system for India that is pluralist,
tarian society. Thereby what the structure context-specific, and organically linked to
of the state and public systems should be the marginalised majorities. Since the po-
is critical, and this within the context of the litical economy approach has been much
in use in analyses of the health system, we
relationship of the state, market, society and
foreground the politics of knowledge in
professional knowledge. Health is political:
these articles, in order to highlight its rel-
as in ‘personal is political’ and as public evance. Building such a vision is work in
health where the collective’s health has to progress and needs much more dialogue
be taken care of by optimal social for inputs from all, as well as drawing of ex-
organisation. This is what the PHC of Alma perience from its operationalisation, in
Ata and the Social Determinant of Health whole or in part. Eventually, the vision itself
Commission tell us. Therefore, we believe requires that the system evolves from in-
that while a democratic, egalitarian society teraction of theory and experience on the
is what can deliver best towards an ground.2 mfc bulletin/feb 2019
Introduction of health services and paramedical health work-
Acknowledging the inequities in access to ers at community level, and (iii) importance of
health care and inequalities in health status across communities in taking care of their health and
and within countries, the Alma Ata declaration ‘participating’ in health care, all to be imple-
focused on strategies for Health for All (HFA). mented as a government responsibility.
“In view of the magnitude of health prob- While this made a dent and did allow for
lems and the inadequate and inequitable distri- other imaginations of health care to surface more
bution of health resources between and within than before, the power of the capitalist economic
countries, and believing that health is a funda- system, including the medical establishment, cre-
mental human right and worldwide social goal, ated almost a backlash. The commercialisation,
the Conference called for a new approach to privatisation and corporatisation that globalisation
health and health care, to close the gap between brought with it from the 1980s to 1990s in differ-
the “haves” and “have-nots”, achieve more eq- ent parts of the world, even more aggressively
uitable distribution of health resources, and at- asserted the techno-centric, bio-medical, institu-
tain a level of health for all the citizens of the tional model of medical services. Therefore, the
world that will permit them to lead a socially and PHC agenda could not gather adequate steam. But
economically productive life.” (WHO and Unicef, since it is a powerful idea, it remained as the back-
1978, p16) drop to any talk of improving population health.
“The gap is widening between the health This is a neat enough narrative and much
“haves” in the affluent countries and the health literature has elaborated on this political economy
have-nots” in the developing world. Moreover, argument for limited implementation of PHC.
this gap is also evident within individual coun- Some have evoked individual country welfare
tries, whatever their level of development.” (p37) policies and their inadequacy of fund allocation
for health as the major limitation (Dreze and Sen,
“...most conventional health care systems
2013). Others have remained focused on health
are becoming increasingly complex and costly
systems development and governance as techni-
and have doubtful social relevance. They have
cal issues, and identified flaws there (Labonté et
been distorted by the dictates of medical technol-
al, 2017). Still others have forcefully brought out
ogy and by the misguided efforts of a medical in-
the technocratic agenda being played out inter-
dustry providing medical consumer goods to so-
nationally and nationally, undermining the Alma
ciety. Even some of the most affluent countries
Ata agenda (Banerji, 1999; Qadeer, 1995). Ear-
have come to realize the disparity between the
lier analyses of implementation focus on major
high care costs and low health benefits of these
shortcomings in implementation of community
systems. Obviously, it is out of the question for
participation, inter-sectoral coordination and pro-
the developing countries to continue importing
motion of appropriate technology (Rohde, Rifkin
them. Other approaches have to be sought.” (p38)
et al, 2008). However, some radical critiques of
But, since it was a negotiated international the document itself have pointed out gaps in its
document that had to be acceptable to all politi- content that led to its subsequent undermining and
cal ideologies of governments all over the world, suggested that the WHO should have led the in-
though it referred to New International Economic ternational establishment in taking a more politi-
Order (WHO and UNICEF, 1978, p2), it left much cal view of health (Navarro, 1984).
of the political economy unstated. It created a
Using an Integrated Political economy and
health systems design document that had to be
Politics of knowledge framework
flexible enough for all country contexts to adopt
and yet to make a dent in the existing model of In this paper we present the limitations in
healthcare. It succeeded in creating an acceptance implementation as an outcome of both the over-
for the idea that (i) health is shaped by the larger all international and national political economy,
context beyond medical care and therefore de- and of the gaps in the document itself. On the
velopment in other sectors is a significant input gaps in the document, we posit that, in addition
for HFA, (ii) importance of the role of outreach to the lack of adequate attention to the political3 mfc bulletin/feb 2019
economy of health, the lack of acknowledgement 5. No addressing of issues of ethics of health
of a ‘politics of knowledge’ and its implications services and medical practice, of corruption
for PHC and for HFA is a major flaw. We see in the health care system, of iatrogenesis re-
the concept of politics of knowledge comple- flecting the power of the medical profession
menting the political economy analyses. and establishment.
A recent analysis on these lines (Priya 2018), 6. Romanticised, unreal notion of ‘the com-
of how the Alma Ata document and health sys- munity’ Diversity, power hierarchies and con-
tems development in India had dealt with the en- flicts of interest within communities not ac-
tity of ‘community’ and ‘community participa- knowledged gender, race, classes.
tion’ as well as ‘appropriate technology’, found 7. Validity of diverse forms of knowledge
it to be a continuity of the colonial mindset and (‘epistemic pluralism’) not acknowledged,
the top-down approach to development. Unless covered merely under ‘culturally acceptable’
the knowledge and choices of laypeople are val- healthcare and use of traditional practitioners
ued, there is little possibility of ‘community par- after training for ‘modern’ primary level care.
ticipation’ especially in decision-making, which Below we briefly discuss these gaps and
is essential for ‘empowerment’. Further, viewing what it implies for HFA-PHC for the present
issues from a community perspective, the analy- times. We underscore the fact that the PHC ap-
sis found “five ‘missing links’ in the dominant proach and principles need to be applied to the
discourse of Health System Development (HSD) entire health system, which includes the wider
policy—the complexity of ‘community’ and dis- determinants of health as well as the health ser-
parities and diversities within; the validity of plu- vices at all levels.
rality of knowledge and its hierarchies; the cul-
ture and ethics of health care providers; the Inputs for Redrafting: PHC 2.0 for HFA Now
unaffordability of the Euro-American institutional Place ill-health in the context of Globalization
model of medical technology-based health care; While the Alma-Ata documents fore-
and the physical, social, and cultural iatrogenesis grounded social inequities within and between
as elaborated by Illich, 1977” (Priya 2018). countries, there is silence on their root causes.
Summarising the Gaps They mention categories of power but don’t ques-
1. Systemic international structural barriers to tion the asymmetry. They are concerned about
health and health care were somewhat referred rising cost of health care but limit the explana-
to, but not addressed—the impact of colonial- tion to medicalization. International trade poli-
ism earlier and commodification of healthcare cies, crafted by World Trade Organization, have
with its medicalisation and allowed exploitation of global south by the glo-
pharmaceuticalisation by the medical indus- bal north in the name of globalization. Interna-
trial complex. tional monetary policies, conceived by World
Bank and International Monetary Fund, have con-
2. The difference and link between Primary sciously spread capitalist ideologies and consum-
level care and PHC as an approach for the erism, and have destroyed public services in low
entire health system was not spelt out with and middle-income countries. Trans-national
clarity. The ambiguity led to confusion that Corporations have not only captured local econo-
facilitated ignoring of the latter and focusing mies, but their greed has irreversibly damaged
only on the former. the environment. These factors have led nations
3. Inadequate attention to irrational use of and governments on a path of development which
technologies and Institutions, with reference is iniquitous and ecologically unsustainable.
only to appropriate technology for primary Health is an obvious victim of this paradigm.
care; These factors have to be explicitly acknowledged
4. Medical professionals and bio-medicine and addressed while re-drafting a PHC statement
continued to be considered supreme as the now. Similarly, the ecological crisis affecting
only source of legitimate knowledge and health of populations in various ways deserves a
thereby retain their power. greater discussion4 mfc bulletin/feb 2019
Be mindful of the politics in/of International health services. It has led to a rise in the cost of
Agencies care and has brought-in irrational and unethical
The World Health Organization claims to be practices in health care. It has become such a
a democratic international organization which strong lobby that it influences public policies at
represents interests of all its member states. How- national and international levels. Consequently,
ever, it has always been under the influence of instead of regulating and socializing this sector,
countries that have been its major sources of the public sector is being pushed into partnerships
funds. Of late, corporate interests have increased with private entities. The new version should dis-
their influence on the organizations, through ex- cuss and address this issue.
plicit public-private global health partnerships, Give Modern and Traditional Medicine their
such as GAVI and GFATM. The impact of this rightful place
power-dynamics is visible in WHO’s prescription The documents hold technologies and spe-
for Universal Health Coverage which focuses on cializations as responsible for the rising cost of
medical care but amputates social determinants health care. In response, they talk about appro-
as a set of issues that need to be addressed sepa- priate technology, referral systems and social
rately. UNICEF was another UN agency which functions of professional health workers. But they
was a close party to Alma-Ata Conference. The don’t question the very system of medicine which
agency took far lesser time than WHO to shun draws its dominance and commercial benefits
comprehensiveness and to start promoting selec- from technology and specialization. In addition,
tivity. These changes in dynamics of international the documents do not adequately acknowledge
organizations have to be considered while re- indigenous systems of medicine which are invari-
drafting PHC. Participation of people’s organi- ably found in all parts of the world. The new ver-
zations at various national, regional and interna- sion of PHC needs to recognize the existence,
tional levels, should be institutionalized for glo- popularity and appropriateness of traditional
bal health decision making. medicine including home-remedies. But it
Expose vested interests behind inappropriate shouldn’t romanticize these systems, and should
technologies instead push the scientific community to devise
suitable ways to understand and validate these
The documents define appropriateness of systems and integrate them at the level of knowl-
health technologies as not only being scientifi- edge and practice. This approach should be fol-
cally sound but also acceptable to their users and lowed not only for health but also for allied is-
beneficiaries, simple enough to be used at periph- sues like water conservation, farming and food
eral levels, locally maintainable and producible storage. At the same time, it should talk about the
at low cost with local renewable material. The high cost and iatrogenesis associated with bio-
fact that selected technology should also be the medicine.
safest possible alternative (for individuals as well
Involve Communities in the process of drafting
as for environment) has not been stated. More-
over, the factors that may influence the process Health, like the concept of democracy,
of choosing a health technology and mechanisms should be by the people, for the people and of the
to counter these factors have been left out. The people. And so should be any policy related to
new version needs to uncover this politics. health. The Alma Ata Conference saw huge par-
ticipation from several governments, UN agen-
Describe the private sector, its problems, and cies and non-governmental agencies in official
remedies relations with WHO/UNICEF. It was preceded
The private sector in medical care may not by a series of democratically organized discus-
have been so problematic in the 1970s, though sions. However, there was an under-representa-
its unabated and unregulated growth could still tion of people’s organizations in these discussions
have been anticipated. It comprises of institutes and in the conference. The process of re-drafting
offering medical education, clinical facilities, di- PHC approach should start from the community
agnostic centres, pharmaceuticals, medical equip- and should involve community- based and com-
ment and devices, software insurance and other munity-oriented organizations.5 mfc bulletin/feb 2019
Flatten the hierarchy to foster team spirit under a single rubric of ‘social’. Besides accessi-
The documents propose that members of bility and affordability, the new version should
community, community health workers, tradi- also ask for dignity in care, and sensitivity to di-
tional medical practitioners and professional versity in general.
health workers should work as a team. The social Acknowledge the power dynamics within
and economic hierarchy between these groups is Community
well known. There is a pecking order even within Alma-Ata documents position community
these professional health workers’ groups. In or- right in the definition of Primary Health Care and
der to flatten this hierarchy, radical changes are calls for the community’s involvement in all
required in the process of selection of candidates stages of the planning cycle. It defines commu-
for different medical and allied courses. In addi- nity as a group of people living together in some
tion, it should necessitate community-based work form of social organization and cohesion. But the
at each level of education and training. Besides, ‘community’ has been presented largely in a ro-
it should talk about empowering each of these mantic fashion and the fractures within this so-
cadres to work in the best interest of people rather cial organization are only weakly acknowledged.
than simply toeing the line drawn by the author-
“A community consists of people living to-
ity of the medical establishment.
gether in some form of social organization and
Elaborate what transformation is needed at sec- cohesion. Its members share in varying degrees
ondary/tertiary levels political, economic, social and cultural charac-
The documents state that principles like ap- teristics, as well as interests and aspirations, in-
propriate technology apply not only to primary cluding health.” (WHO-UNICEF, 1978, p49)
health care in the community but also to all other The documents consider it advantageous if
levels. They also express the need for reorienta- community chooses its Community Health Work-
tion of these levels so as to gear them towards ers, but doesn’t warn how complex this exercise
supporting primary health care. But due to a dis- can be. The power structures within the commu-
proportionate focus on primary level of care, the nity may not let certain issues to ever surface,
documents fail to convey the idea that other lev- and these need to be explicitly questioned. The
els of care should also imbibe principles of the new version of PHC has to be more elaborate on
primary health care approach. The new version this account.
should detail how secondary and tertiary levels
Clarify who all represent the community
of care should transform themselves in the spirit
of PHC. At all levels of planning, the documents pro-
pose community representatives in decision mak-
Problematize, and address, social vulnerabili-
ing to pursue community interests but does not
ties Alma-Ata documents recognize women as
spell out the principles of community represen-
one of the vulnerable groups having special needs.
tation. The new version should be more specific
But they limit to biological vulnerabilities by fo-
about who all should represent community inter-
cusing on the health needs during pregnancy and
ests, including socially conscious and dedicated
lactation. They don’t question, or even acknowl-
persons from community/community-based
edge, patriarchy as leading to social vulnerabil-
organisations and representation of all commu-
ity and affecting the health of women. In fact,
nities, especially those lower in the social hierar-
they essentialize the caregiver role of women and
chy. In addition, the new version should define
don’t acknowledge this as their unpaid labour.
the processes through which such representatives
There is no mention of gender violence. The new
gather a sense of what people on the ground think.
version of PHC document should explain, and
address, women’s health issues in a more com- Empower the Community, give enabling envi-
prehensive way. Similarly, the new version should ronment
specifically problematize and address vulnerabili- The documents call for managerial control
ties based on colour, ethnicity, sexuality, religion, through the community but leaves technical guid-
caste and ability rather than clubbing them all ance entirely on other levels of the health sys-6 mfc bulletin/feb 2019
tem. They expect that community should be will- sion of PHC should devote more space to this
ing to learn, and talk about harmonization of issue.
views at community level. By doing so, they dis- Explicating a Cohering Theoretical Frame
regard the knowledge that the community may
To provide a coherent theoretical frame, we
already be having. It is confusing whether the
suggest adopting what has been proposed as a
documents wish to empower the community to
Holistic Health Systems Approach (HHSA) that
decide for itself by providing an enabling envi-
attempts to provide health systems analysis a
ronment, or they want community’s cooperation
framework that combines political economy and
and acceptance for implementing what has been
the politics of knowledge. HHSA links the mi-
pre-decided at a higher level. The new version
cro, meso and macro levels of health systems in-
should state the role of community in very clear
corporating the following: diverse health related
terms. In addition, it should build-in social audit
world-views and perceptions; technologies and
and grievance redressal mechanisms if commu-
practices of health promotion, disease prevention,
nities are to exercise managerial control. It should
diagnosis and treatment, palliation and rehabili-
caution against burdening community volunteers
tation; the modes of utilisation of health-related
with formal daily duties. Involving them in the
knowledge from self-care within families to in-
technology assessment, monitoring/supervision
stitutional services at a societal level; ontologies,
and planning processes should be undertaken in
epistemologies and methodologies of health
ways that welcome their bringing the knowledge
knowledge systems as well as institutional struc-
of local social context and local health knowl-
tures and regulatory mechanisms and their po-
edge into the health system.
litical economy, social and cultural moorings
Elaborate on measures to strengthen individual, (Priya & Kurian, 2018).
family and community levels
The bottom line
If individual, family and community are to
Alma-Ata envisioned a health system which
be the central core of health care and self-reli-
caters to preventive, promotive, curative, pallia-
ance, people’s control to be its principles, as stated
tive and rehabilitative needs of all, irrespective
in the Alma Ata documents, then each of these
of their ability to pay. This system should take
levels needs to be better understood and ad-
health planning and health care services as close
dressed. Each of these have different dynamics
to people as possible. The technology deployed
and requirements and it is not enough to address
to further the services should be empowering and
them as ‘community’ alone.
should enhance self-reliance. The system should
Acknowledge violence as a determinant and em- not be fragmented and should reach out to all sec-
phasize on peace tors which can, directly or indirectly, influence
The Alma-Ata Declaration, in its last point, health. The new version has to necessarily carry
says that health for all can be attained if the these basic principles of Primary Health Care for-
world’s resources are devoted to peaceful aims ward with a more theoretically coherent and op-
instead of armaments and military conflicts. erationally concrete articulation of the linkages.
Armed violence perpetrated by one country over
Thereby, at least three interpretations of PHC
the other, and that staged by state and non-state
are possible from the Alma Ata document (Priya,
actors within countries has been a long-standing
2018):
reality for many parts of the world. Structural vio-
lence, within and across countries, has to be ac- (i) Primary-level care with a feasible, afford-
knowledged in this context. Increasing violent able, ‘essential health care’ package that has
crimes, social conflict and communal violence become known as Selective Primary Health
need to be acknowledged as affecting physical Care, based on primary-level care and ‘com-
and mental health as well as healthcare access. munity mobilization’ through the campaign
All forms of violence not only affect health care mode, as adopted for the RCH and Polio
services but also prevent any growth and devel- Eradication programmes (Chen and Cash
opment activity from taking root. The new ver- 1988);7 mfc bulletin/feb 2019
(ii) Comprehensive Primary Health Care of UHC, which has advanced down the SPHC
(CPHC) with primary-level care as central to path. The Astana documents now do acknowl-
HSD and appropriate secondary and tertiary edge the role of traditional knowledge, but in
care to support it, including conventional (i.e. passing (World Health Organisation, 2018).
modern) medical and non-medical interven- Thereby, the Alma Ata document set out
tions that are preventive, promotive, curative, health systems design principles but with no co-
and rehabilitative, relying on community par- hering theoretical frame that assessed the social,
ticipation, appropriate technology and mea- economic, cultural and political structures that
sures to deal with the wider determinants of underlie the state of health and healthcare. We
health; argue that inherent in all these factors is the poli-
(iii) The CPHC as in ii, and including the lo- tics of knowledge of lay versus expert knowledge,
cal folk knowledge-based home and commu- of ‘modern scientific’ versus ‘traditional non-sci-
nity care at primary level, backed up by the entific’ systems of knowledge, and of ‘bio-medi-
institutional primary, secondary, and tertiary cal, objective’ versus ‘social science, subjective’
levels. A bottom up structure and functioning knowledge and ignoring this is part of the politi-
of the health system are inherent to this inter- cal economy of PHC. Therefore, we suggest that
pretation. Shift to a decentralised, pluralist the political economy and political of knowledge
framing of the health services design, and a frames must be integral to the analysis of health
polity, governance and economic develop- systems in general, including that of the vision of
ment model that supports this, would have to PHC.
happen in tandem. Acknowledgement
The vision of the Alma Ata document ar- A course on ‘Politics of Health: Towards a
ticulated the second stance most clearly. The Sustainable Health Care System’ was organized
ambiguities already pointed out in it, allowed it by South Asian Dialogues for Ecological Democ-
to be interpreted also as SPHC by those who were racy (SADED) in collaboration with
more comfortable with or interested in a top down Sambhaavnaa Institute of Public Policy and Poli-
medicalised view. Since the document does ac- tics (Palanpur, Himachal Pradesh) in April 2017.
knowledge the role of community participation The participants reviewed the Alma-Ata Decla-
and of traditional practitioners due to their trust ration and the conference report on PHC, and
in the community, it opens a window for the third compared these documents with other health char-
interpretation (Young, 1983; Unnikrishnan, ters [Indian People’s Health Charter (PHM
2010). The Chinese health care system had al- 2000a), People’s Charter for Health (PHM
ready demonstrated implementation of this third 2000b), Cuenca Declaration (PHM 2005) and a
version, with inclusion of community collectives document on ‘Approach to National Health Policy
and use of local traditional knowledge as well as and Budget’ (SADED 2014) drafted by Health
institutional practice of plural medical traditions Swaraj (a working group with SADED)]. On the
nationally. The Alma Ata document foregrounded last day of the course, each group presented a cri-
China’s ‘barefoot doctor’ concept while ignoring tique of Alma-Ata’s PHC approach in light of the
the other dimensions. Civil society experiments discussions and reading on politics of health dur-
such as of Jamkhed and Deenabandhupuram in ing the last four days. They also expressed their
India had also integrated local illiterate women thoughts about how the approach should be re-
of lower castes into their community level care drafted for the present context. The authors thank
using local traditional practices along with train- all the resource persons and all the participants
ing in modern primary level measures. Over the of the ‘Politics of Health’ course for their com-
years, several countries have attempted to offi- ments and insights that have been woven into this
cially include local health traditions in their health article.
care system (Bichmann, 1979; Mignone et al.,
Also to be acknowledged is the JNU PHC
2007; Campbell-Hall et al, 2010). Yet these con-
Version 2.0 Study Group that greatly helped de-
tinue to be abandoned in the primary level care
velop ideas further, as did discussions at the MFC8 mfc bulletin/feb 2019
mid-annual meet 2018. All the authors are mem- view of perspectives and challenges.14(6),
bers of this group and/or of the Politics of Health pp.723-743.
workshops. PHM, 2000a. Indian People’s Health Char-
Email: ritupriyajnu@gmail.com ter: Adopted at the Indian People’s Health As-
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Journal of Health Services, 14(2), pp.159-172 medical cultures to modern primary health care.
Payyappallimana, U., 2010. Role of tradi- Social Science & Medicine, 17(16), pp.1205-
tional medicine in primary health care: An over- 1211.9 mfc bulletin/feb 2019
Some Thoughts on Health for All: The rationale for engaging with the politics of knowledge
Rakhal Gaitonde, Ritu Priya, Amitabha Sarkar, Sayan Das,
Prachinkumar Ghodajkar, Mohit P. Gandhi
This paper (the second of three in the se- (who draw on the Political economy approach)
ries) explains the basis of the focus on Politics of draw on.
Knowledge that has been introduced in the first We follow this line of exploration in the rest
paper, it highlights a number of explicit and im- of the paper in the following way – in the next
plicit critiques of the taken for grantedness of the section we present different critiques of the domi-
knowledge base on which the bio-medical sys- nant (hegemonic) knowledge system. We follow
tem is premised. While the paper attempts to de- this with a section that reviews theories of dis-
lineate some broad directions an alternative course and its role in producing ‘knowledge’ dem-
framework could take, the next paper (paper three onstrating the key role played by knowledge and
in the series) translates these into health system its material and symbolic consequences. We then
design for Health for ALL. have a section that integrates these insights and
Introduction further defines the Politics of Knowledge ap-
The continued discussion of Health for All proach. We conclude by pointing to the critical-
in its fortieth year is testament not only to its con- ity of such an approach to the struggle for Health
tinued relevance, but equally to the fact that it for All, as well as a key avenues for further work.
has not been achieved. While renewing our com- Critique of the dominant knowledge system
mitment to Health for ALL, it is important to re- There are a number of perspectives arising
flect on why it has remained unachievable, and out of a diverse range of knowledges and prac-
attempt to critically look at the adequacy of the tices that pose a challenge to the dominance of
various perspectives from which critiques have the present, linear, bio-medical knowledge based
been made. on ‘science’ that dominates thinking in health and
Most analyses have framed this critique in public health. It is useful to first list these before
terms of Political Economy and have focused on going on to develop a framework for a more over-
the individual or institutional level for analysis, arching critique. In the following sub-sections
and have been alluded to in the first paper of this we will be discussing the critiques (both explicit
series. The institution is now recognized as a key and implicit) that arise broadly from – (a) within
site / level for the production and reproduction of science itself; (b) from lay practice and experi-
trends in health outcomes obtaining in a particu- ence; (c) from other major paradigms/epistemo-
lar socio-economic-political-cutural-ecological logical approaches; and (d)our own critical frame-
(SEPCE) setting. The political economy approach work that points to the value of different indig-
has focused on the distribution of power in these enous knowledge and practice systems.
institutions, as well as in the evolution of these Each sub-section does not claim to be a com-
institutions. This implies that the institutions/ac- prehensive summary of the critique presented by
tors have a role in ‘channeling’ the power that each of the perspectives, but merely tries to point
constitutes the politics underlying a particular to the major direction of that critique. The idea
organisation, which in turn (and in aggregate) being to draw on these broadly as we develop a
constitute the health system. Thus particular in- larger framework for understanding the Politics
stitutional designs are seen as being emergent of Knowledge.
from the prevalent configuration of power.1 Critiques from within science
In this paper we follow a politics of knowl- Developments within science in the twenti-
edge approach to critique the limitations of a po- eth century have led to the complicating of the
litical economy model of health care and reflect notion of truth and certainty.2 Examples are Ilya
on alternatives. A politics of knowledge approach Prigogine’s work in chemistry, Benoit
urges one to go beyond the political economy Mandelbrot’s work in the mathematics of fractals
analysis of power by pointing to and exploring and randomness, Humberto Maturana and
the taken for granted model of certainty and truth Francesco Varela’s work in relation to the biol-
of a given form of knowledge, which both the ogy of cognition, and Stafford Beer’s work in
mainstream institutions as well as their critics relation to organizational science. These have all10 mfc bulletin/feb 2019
challenged simplistic notions of truth and knowl- gards to the legitimacy of science. However more
edge about truth. This is not to mention some if importantly we have seen the way in which un-
the critical work in relation to the uncertainty of certainty inherent in science (either due to the
knowledge in the field of quantum mechanics, actual topic, or the lack of good quality research)
stemming from for example Heisenberg’s has been exploited for profit, for example in the
Uncertainity Principle. case of diesel(and other products like chromium,
While these various scientific developments lead and plastics which manufacturers of danger-
contributed greatly to a more complex and nu- ous products avoid environmental regulation by
anced understanding of reality, one aspect of this manufactured uncertainity) and tobacco4. Further
development of note is the emerging understand- we have seen the emergence of “corporate epide-
ing of the relationship between the legitimacy of miology” and other similar modes of enquiry that
knowledge to the dimension at which one tests studies the distortion of science by corporate
the results of that knowledge. The most straight profit5.
forward example of this is in physics where it is This whole development and struggle points
now clear that Newton’s laws were not so much to the way in which the present systems of man-
proved false by the Theory of Relativity, but were
discovered to be relevant in only particular di- agement of the scientific endeavour have left the
mensions of experience. Thus in our day to day gates open for exploitation for corporate greed at
life and visual reality it continues to play a major the cost of individual and community welfare –
role. It is just that in various other dimensions / especially if the communities involved are vul-
scale like the sub-atomic or realm of space for nerable and marginalized. Such communities do
example that it is not valid as its assumptions do in fact constitute the large majority.
not hold. The challenge posed by a number of people’s
Germane to this discussion of a critique of movements like the Treatment Action Campaign
dominant science from within is also the insight (TAC), the People’s Health Movement (PHM),
of the inter-dependence of various parts of a sys- the Right to Food (RtF) Campaign, and the Envi-
tem, however ‘distant’ they may seem in ‘real- ronment movement have been at the fore front of
ity’, and the extreme sensitivity to initial condi- critiquing science through the foregrounding of
tions – which points to the importance of history a number of alternative perspectives/ paradigms,
in understanding various paths of development challenging the values that facilitate corporate in-
and evolution of systems. This insight into initial
fluence. Thus for example TAC, PHM and RtF
conditions and interdependence destabilizes a
naive faith in the universality of a strictly linear have all foregrounded Human Rights as a key
view of science. counter balance to designs and policies that favour
private profit, and the environment movement has
Philosophers of science, especially those in-
fluenced by ‘complexity’ and the study of ‘wicked foregrounded the “precautionary principle”
problems’ point either to different orders or dif- (which implies that there is a social responsibil-
ferent phases of science. These understandings ity to protect people from exposure to potentially
call for a recognition of the limitations of a purely harmful substances even when scientific knowl-
‘neutral’ approach to science as data gathering edge is lacking, but investigation has found plau-
about a ‘single reality’. These approaches call for sible risk) to counterbalance a more short sighted
greater reflexivity on the part of the researcher profit driven governance of scientific evidence
herself, which includes interrogating the biases, about various chemicals.
influences and perspectives of the researcher that A third example is the tendency to neglect /
influence the construction of knowledge. Further
ignore social and behavioural and structural ap-
‘harder’ versions call for the similar interroga-
tion of the ‘system’ as a whole of which the re- proaches to health, to the benefit of technologi-
searcher is a part. Thus there is a clear emerging cal quick fixes6. Much of this is emanating from
strand of thought from within science that ques- the mindset that technological solutions are the
tions the universalist assumptions on which ‘sci- best way to improve and maintain population and
entific legitimacy’ is premised3. individual health. It is the dominant institutional
Distortions in the practice of science structures and the centralised structure of knowl-
The increasing exposés of the way in which edge itself that allows the chosen ‘experts’ to dic-
corporate interests have distorted ‘science’ deeply tate what is legitimate and what is not in avail-
shakes the confidence of the lay person with re- able knowledge(s).11 mfc bulletin/feb 2019
This again is a clear reflection of the fact algorithms to access a number of systems for dif-
that what purports to be scientific knowledge may ferent illnesses. Again showing the willingness
on occasion in fact only be a version of corporate of those who consume health care to be eclectic
influenced greed dressed up as science. The fact and open to experimentation.
that this is possible and indeed we are coming (d) Finally there are a number of examples
across more and more examples – points to the of patients who organize themselves and attempt
vulnerability of the scientific process to hijack – to influence various aspects of the way knowl-
and begs the question of more robust structures edge is produced. This potentially leads to
of evaluation and governance. changes in priorities of research, the questions
Critiques from practice and experience asked and indeed potentially the uptake of re-
Critiques from the perspective of the user / search into practice8.
provider can be discussed from at least four points Critique from academic perspectives
of view – (a) the modification of guidelines dur- Bodies of knowledge like poststructuralism
ing their implementation in practice by frontline (Foucault), and Subaltern Studies and the work
providers; (b) inter-system referral of patients by of those such as Illich, Ashis Nandy, Vandana
doctors; (c) multiple – system usage by patients Shiva, Shiv Vishvanathan, Manu Kothari and
and patient dependence particular system / refusal Lopa Mehta etc., all are examples of strong cri-
to accept bio-medicine; and (d) the experience tiques of modern science and application of the
and critique offered by various patient’s move- scientific method in particular fields or at the
ments. philosophical level. Feminist approaches to
(a) Modification of guidelines - Research on knowledge including non-hierarchical and mul-
the implementation of evidence led to a number tiple epistemological approaches have been ap-
of studies that looked at the way in which practi- plied to health-related knowledge and practices,
tioners interpreted evidence and used it to guide critiquing the hegemony of doctors and of bio-
practice. This research showed that despite train- medicine.
ing and familiarity with the guidelines, practitio- (Note this is a partial list, but just aims to
ners tended to ‘adapt’ the guidelines to suit the give the reader a sense of the various critiques.
local context. The research pointed out that rather We have tended to lump various systems together
than see these adaptations as failings or errors, – this is definitely not good practice. But we are
one needed to see these as ways of “sense mak- doing so as the main aim is a critique of bio-medi-
ing”. This led to a very interesting line of work cine. A further differentiation within the broad
which drew on various aspects of the concept of umbrella terms is definitely called for and exists
“tacit knowledge” and other related aspects to too).
posit the concept of “Mindlines” which are ways
Our critique from the perspectives aligned with
in which evidence is interpreted and put into prac-
indigenous / alternative knowledge systems
tice based on the opinions of trusted peers and
experience in the local situations7. Like all knowledge systems, each indig-
enous/alternative system arose from an eco-so-
(b) Cross – referral – Despite the obvious
cial context. It is unlikely that any one knowl-
fundamental differences between various systems
edge system may be considered perfect therefore,
of medicine and the dominance of the so-called
each knowledge system has its own issues
modern medicine in large parts of the world – at
strengths and limitations. There have been unre-
least at the Global / national level – there are a
lenting criticisms of such alternatives. Critiques
number of instances where doctors from one sys-
of various indigenous systems include pointing
tem refer to doctors from another system – either out the way in which more formalised and text-
at the request of their patient, or indeed from in- based systems tend to dominate over the more
dividual conviction of their usefulness. Thus there experience based folk medicine. There are some
is a seeming willingness at the level of frontline serious critiques as to the caste, class and gender
practice to engage with widely different ap- biases of some of the more text based and
proaches to reality. formalised systems like Ayurveda and so on.
(c) Patients choice – there are a number of More recent academic work has also pointed
instances where patients reject allopathy / mod- out to the way in which streams within these sys-
ern medicine completely, alternatively patients tems have responded to and adapted to the mar-
and communities develop sophisticated rules / ket-based economy with commodification and12 mfc bulletin/feb 2019
packaging which is clearly against the basic te- ● The above leads to Trust – with trust be-
nets of these systems. The whole range of ing such an important part of the doctor-pa-
Patanjali products in the market may be taken as tient relationship. However the rise of
the ultimate expression of this neo-liberal influ- commodified technological solutions, and the
ence on traditional systems like Ayurveda. consequent rent seeking that is possible has
Despite the above critiques we believe that created a situation in which trust no longer is
non-modern knowledge systems provide an in- seen as essential for efficacy – of the technol-
valuable perspective from which to critique the ogy or for the profit of the system. This clearly
present hegemonic system. A very preliminary undermines all healing – as seen in the grow-
listing of the strengths of this perspective would ing dissatisfaction with the technology driven
in our opinion include: health system and the violence against doc-
tors. Trust leads to, and also results from, a
● Using completely different ontologies – legitimation of lay people’s/subaltern knowl-
or conceptualizations of reality. Thus concepts edge and practice. The legitimation of lay
like tridosha, or yin and yang for example are people’s/subaltern knowledge and practice
quite inexplicable in terms of modern bio-medi- will also promote self-confidence to enable
cine. The doshas, humors etc., also closely link questioning of the dominant forms of practice
to the question of balance which is a key aspect and a more critical utilisation of even allopa-
of many knowledge systems. The concept of thy, contributing to creating a politics of health
balance points to a more dynamic with the lay people/subaltern sections.
conceptualization. Further balance also is con- ● Knowledge management in terms of the
ceptualized in a multi-level way which again creation of new knowledge, its legitimation
challenges a purely static and universalist view process, governing the uses of new knowledge
of health. etc.— Each system has many implicit rules
● Some systems, especially folk traditions for these which are quite different from mod-
and to some extent ayurveda, siddha, sowa ern science / bio-medicine. These need to be
rigpa (Tibetan medicine) and unani are deeply mapped and studied.
connected to local eco-systems. And further, Towards a framework
these codified textual systems (such as
ayurveda, unani, siddha and sowa rigpa) are In order to develop a framework for a cri-
closely linked to the folk knowledge and prac- tique of science from the perspective of the Poli-
tics of Knowledge, we draw upon three broad
tices. While modern medicine is now talking strands. These include – (a) the insights from com-
about patient tailored medicine, indigenous plexity in terms of the different orders / phases of
systems have at their core the uniqueness of science; and (b) the strengths of dealing with the
each individual and factor in layers upon lay- issue from the vantage point of discourse theory.
ers of influences to conceptualize a truly com- These are discussed next.
plex set of determinants. Again this sort of ho-
listic approach is lacking in modern science / Approaches from within science
medicine. Thomas Kuhn points to the way in which a
● There is a critique of the objectification paradig matically dominant way of thinking will
of the patient in pursuit of the standardization relegate to the periphery all the questions that
of treatment in bio-medicine, and thereby its challenge it. This shows the importance of ‘insti-
implicitly coercive bureaucratisation, with, on tutionalized’ science and the power of the insti-
the other hand, a celebration of the singular tution to define what is legitimate and what is
and the diverse by most other knowledge sys- not. This defines a period of normal science. At
specific points in history, there are ruptures that
tems. The decentralised nature of folk medi-
cine and also to an extent of the textual forms, shift the paradigm. We call for such a paradigm
allows systemically for greater diversity and shift in our pursuit of meaningful and effective
context specificity. De-commodified / de- healthcare.
commercialised practice of (while Ayurveda Insights from complexity and second-order
has been intensely commodified, Patanjali be- science
ing the peak example) folk healers continues As already discussed in the first section of
to a large extent with their not charging for this paper the insights from understanding com-
consultations, leading to an alternative imagi- plexity and uncertainty point to the need for in-
nation in terms of commodified practice. Heal- creased reflexivity, not only demanding that we
ing is then viewed as a vocation and knowl- focus our attention on the researcher, but also the
edge acquired and held in trust for the benefit very system of production of knowledge within
of all. which the researcher is embedded.13 mfc bulletin/feb 2019
Discourse a certain point in time). It has been pointed out
Discourse theory points out that institutions that one of the biggest contributions of Nazi ge-
draw on rules and norms defined by the domi- netic experiments was in fact the discrediting of
nant / hegemonic discourse currently in place eugenics once and for all (to a greater or lesser
(there may be many competing discourses with extent). In such a situation suddenly those par-
one being dominant at any given point of time). ticular uses and interpretations were no longer
Discourse is said to create particular ‘subject po- considered legitimate. In fact officers, positions
sitions’ - which in essence define what legiti- and units dedicated to the eugenics project sim-
mate roles people may take on / play out in a given ply disappeared or had to change their essential
situation, and ‘ways of seeing’ - which include character as described for example in the work of
what are considered as legitimate ways of seeing Siddhartha Mukherjee11. We have taken this ex-
the world and the legitimate questions that one treme example of eugenics because it rather
may ask of it (Kuhn’s concept of the paradigm clearly highlights our observation regarding the
defines such questions). Such discourse also de- dynamic interplay between institutions and
fines the implicit order and relationships between knowledge, and especially the key role played
these positions and roles and ways of seeing. Over by knowledge to prop up particular institutions /
time these positions / relationships and rules of roles / ways of seeing and doing. It also high-
acceptable behaviour crystallize or get sedimented lights the manner in which a shift in the para-
into forms of institutions that we come to recog- digm can result in the collapse and regeneration,
nize in society, acquiring as it were a taken for i.e., the transformation, of old institutions.
granted nature9,10. Thus we find that in health systems today
It is increasingly understood further that in- the power of the knowledge generated from
stitutions themselves depend for their legitima- randomised clinical trials as being considered the
tion on ‘knowledge’. This knowledge is in turn ‘truth’ and thus those associated with such trials
produced by these very same institutions. Insti- – scientists and funders (increasingly drug com-
tutions and knowledge are thus to be seen as very panies) – have the most power, compared to other
closely related and constitutive of each other over forms of knowledge including qualitative, and
time. Thus power ensures that what may in fact even lay forms of knowledge. Here we find that a
be arbitrary choices in terms of knowledge are particular conceptualization (and seemingly natu-
sedimented into ‘truths’ through this interplay9,10. ral perception) of what is considered ‘the best’
research method – creates the situations of par-
Thus it is important for us to appreciate that ticular formulations and relations between experts
power acts (ie. Has material consequences) and lay persons.
through both ‘rules of distribution’ (in other words
how institutions will act) which is covered by The question with regard to clinical trials is
political economy, as well as the reference to not a solely methodological question, but it asks
‘knowledge’ that is used to prop up a system. We us to explore the effect of considering it as the
propose thus that any attempt at understanding most accurate / highest form of research – on the
and acting upon power in the health system has study of and understanding of reality. Not only is
to necessarily engage with both aspects. there the need to convert everything into objec-
tive, verifiable data that can be collected in a
Knowledge works by at least two broad blinded fashion – thus necessarily narrowing /
mechanisms – one is by lending legitimacy to blunting the scope of what can be measured. The
institutions and subject positions and roles de- other process of controlling and randomizing –
fined by particular discourses, and the second is done to create circumstances of being able to
by reinforcing a particular way of looking at the measure the ‘pure’ effect of a particular interven-
universe. Of course these are dynamic and itera- tion – belies the understanding of reality based
tive processes. on complex interdependencies and multi-level and
Particular forms and interpretations of data intersecting causation.
are supported by those in positions of power. This Another role which knowledge plays very
in turn furthers their positions and legitimacy. influentially is in the problematization of a given
Eugenics may be taken as an extreme example, issue. Thus a particular research paradigm defines
where racially and elitist motivated interpretations out / crowds out competing paradigms. Thus re-
of data by influential persons (including the Su- search has shown the way in which technologi-
preme Court of the USA) – further legitimised cal quick fixes crowd out socio-behavioural ap-
these particular interpretations and solidified the proaches (referred to above).
importance of those holding / creating and up-
holding such knowledge. Further it may be shown Similarly one can talk about the effects of
that all future knowledge developed in genetics the Green Revolution as being remarkable along
seemed to feed this and further legitimize it (upto particular narrow dimensions related to grainYou can also read
