Lay workers in primary health care: Victims in the process of social transformation

The training and utilization of non-professional Primary Health Care Workers (PHCW's) is currently a major strategy for meeting the minimal health needs of the four-fifths of the world's population without permanent access to care. Increasingly, however, in countries where the wealth is in the hands of the few, PHCW's are become victims of political violence. Because the implementation of the Primary Health Care Model in these Third World countries requires a major transformation of the existing socioeconomic structures, the PHCW may be knowingly or unknowingly placed in a vulnerable situation. This relates to the various functions--both latent and manifest--of the PHCW's role as well as to the way they have been trained and utilized. That PHCW's may be utilized as vehicles of a nation's overall political strategy is demonstrated by the role of the 'barefoot' doctors during the cultural revolution in China. In contradistinction, they may be trained and utilized as part of a government's strategy to 'take over' struggling liberation groups and to 'cool out' potentially explosive situations. In addition, they may be used as spies as may their foreign counterparts and trainers. PHCW's trained in programs which encourage health workers to participate with the community in a critical analysis of the root causes of their ill health may be subject to reprisals if, in fact, they actually participate with the community in the development and implementation of strategies designed to combat the underlying social causes of their problems. For this reason, to protect the PHCW's, a number of community-based health programs are assuming a low profile and questioning the wisdom of their 'consciousness-raising' educational methods. It may be, however, that any health worker who is conscientiously trying to deliver health care in the context of gross socioeconomic inequity is at risk. By the very virtue of their healing role, PHCW's derive social status and influence. Particularly within the context of civil unrest, the political forces would be sensitive to the PHCW's position in the community. Further, accessible health care within a community may result in a certain self-reliance and freedom from the social institutions which may have served to maintain the social class structure of the larger society, a situation potentially threatening to the ruling elite. Finally, by treating the ills of the system, PHCW's can be thought of as latent critics of the system. They are, therefore, vulnerable in times of conflict, not because of who they are or what they are doing, but because of what they represent.