Daniel Becker, a pediatrician with a background in public health, promotes citizen responsibility for community health, engaging residents, local business, and government to commit resources and act responsibly. Drawing on Daniel's innovative community-participation programs, citizens develop local networks to advance quality of life in the Brazilian urban slum settlements known as favelas.
The New Idea
With 11 years of experience as a health promoter, Daniel is working to improve the health and overall quality of life for people in the poorest sectors of Brazilian society by stimulating the design and execution of community solutions to social problems. Daniel develops partnerships between community groups, public offices, businesses, and health specialists. He and his team mobilize community members through a series of participatory workshops aimed at establishing Health Development Groups. This group, made up of local representatives from various sectors, is responsible for the direction and advancement of the program. The groups identify the major health problems in their communities, define priorities, propose solutions, design projects, and form partnerships with other organizations and community groups to carry out these objectives.
Promotion of good health, in contrast with the treatment of illness, was recognized within the medical community as a global priority in 1986 during the World Health Organization International Conference on Health Promotion. The conference participants recognized "peace, equity, education, housing, empowerment, a stable ecosystem, and the conservation of natural resources" as fundamental health prerequisites. However, in most countries, health policymakers lack the will or ability to transition from the focus on traditional clinical medical attention to a more proactive and preventative approach. In Brazil, government health services do not effectively reach the poorest populations that are most in need because of inadequate facilities, low-paid health professionals, and lack and misallocation of resources. Curative health services generally achieve low rates of success as they tend to treat only the most immediate problems rather than identifying the source of illness, causing dissatisfaction among clientele and frustration among providers.
Urban slums at the peripheries of large cities are areas in which poverty, violence, pollution, and crime compromise the healthy and productive development of their inhabitants. Such regions are typically forgotten by public policymakers and are undesirable destinations for medical professionals and volunteers. Furthermore, because of the lack of favela citizens' organizations or advocacy groups, government health workers and social workers assigned to these areas have little choice but to work constrained by a narrow scope of activities.
The region of Santa Cruz on the periphery of Rio de Janeiro is one example of the grave situation affecting the urban poor throughout the country. This region, with nearly 300,000 inhabitants, contains several impoverished communities with high violence and unemployment rates. The area maintains the lowest score on the Human Development Index of the metropolitan region, characterized by a scarcity of public services, insufficient transportation services, remoteness from health professionals, and rapid population growth. Santa Cruz also contends with a high population density, an infant mortality rate of 22 deaths for every 1,000 births, and a high adolescent pregnancy rate. The population has low access to health and education services. Furthermore, under such poor conditions Santa Cruz cannot attract or keep health professionals working in the area.
Daniel is helping to show poor community members how to solve their health problems within the framework of participative planning and implementation of disease prevention and health promotion. He founded the Center for Health Promotion with a team of professionals in 1993. In 1999 he started to mobilize inhabitants of Santa Cruz to improve the health infrastructure of favela communities there. Using an international program that Daniel helped to develop, "Problem Solving for Better Health," the community members of Santa Cruz designed 47 intervention projects to solve the problems they identified in the region. The majority of these actions were simple and could be executed through more efficient use of available resources. The project designers, many of whom had never been involved in community matters, become the primary social agents responsible for implementing the projects with support from the health development groups and the Center for Health Promotion. Examples of these initiatives run the gamut of community health: a teacher opened up school playgrounds for weekend activities for young people and their families; a housewife inaugurated weekend meetings to teach expectant mothers the importance of breast-feeding; a teacher reduced violence in her school through music and dance workshops; and a community member mapped the employment needs of 50 area companies to create a local employment reference center.
For the past year the Santa Cruz initiative has been in the phase of execution and follow-through. Daniel and the center's field staff provide the following supports to advance the program: support in project implementation (supervision, evaluation, and dissemination); incorporation of the model projects in public policies; incorporation and training of new partners to the Development Group to promote local sustainability; and fundraising and seed funding for selected projects.
A project is considered completed when the people have fully benefited and the significant problem faced by the group, institution, or community has been solved. Completion also leads to the implementation of a social activity that can serve as a model for similar situations. For this reason, Daniel is publishing a notebook of best practices about the Santa Cruz initiative to offer public authorities good ideas that work and can be replicated and expanded to benefit a larger number of individuals.
Daniel's idea for health promotion serves as a catalyst for community mobilization and social change by stimulating participation, the creation of solutions, and intersector cooperation in the region. The Development Group is expanding its membership, meeting independently, and mobilizing the business sector in the region to collaborate. The group's plans include bringing in the Family Health Program of the government health system, construction of a new school, and concentration of activities in the poorest favela in the region. Daniel tracks the change in community health by several indicators: quantitative, e.g., percentage of mothers breast-feeding and vaccination rates, and qualitative, e.g., observation and the transition from passive to social actors.
As the Santa Cruz initiative continues to grow, Daniel plans to replicate the project in other municipalities of the Rio de Janeiro metropolitan area and afterward in other regions of Brazil. The Santa Cruz initiative has already attracted international attention from organizations in other countries for its innovation and results. Building on his contacts and reputation in the field, Daniel is working to engage policymakers in Rio de Janeiro, a state that carries the weight for effecting policy throughout the country, in a dialogue to turn this initiative into national policy. Daniel has already been invited by the Dreyfus Health Foundation, which implements Problem Solving for Better Health, to assist teams in other Latin American countries to develop similar programs, and he will continue to use these contacts to spread his idea.
With extensive experience in social action and leadership, Daniel entered medical school at 17, believing that he would cure the world. While a good student, he did not feel driven by the clinical arena where he spent the day surrounded by sickness and hopelessness. Because of his love of children, he opted for a residency in pediatrics but again he had the feeling that direct care was not addressing adequately the systems that would help children lead healthier lives.
Frustrated by his experience, Daniel went to Europe to explore new opportunities in medicine. Again he was disillusioned by a pediatrics program that fell short of addressing the social problems affecting poor children's health. He left to take a position working for the organization Doctors Without Borders at a Cambodian refugee camp in Thailand. Treating refugees who had lived through years of terror, Daniel came to understand people's power to survive and find ways to overcome the most overwhelming problems. In Thailand Daniel also met a man whose concept of health included addressing a high suicide rate, domestic violence, and malnutrition in the camp. Daniel learned that medicine alone did not make for good health. Dignity, music, religion, and meditation often produce more in terms of good health than a doctor is able to achieve within a hospital or a clinic.
Returning to Brazil in 1989, Daniel integrated this philosophy into his work and began to incorporate elements of prevention and good health promotion, including environmental preservation and nutrition, into his work. Working in a favela in Rio, Daniel sought to create an innovative experience in the assistance models for low-income populations in urban areas. Previously, the health system required marginalized populations from distant neighborhoods or slums to come to a clinic for routine and emergency medical attention. He instigated a radical change in the project for which he was working, substituting the group of medical specialists with a general internist (family doctor), supported by a community health agent and a social assistant. The positive results of this model caught the attention of Rio de Janeiro's Secretary Ministry of Health, who invited Daniel to design and implement the first Family Health Program. Together with other groups, Daniel helped the program to grow and reach the Ministry of Health. Now national policy, the program has changed the lives of millions of people in the country.
Daniel founded the Center for Health Promotion to give him a base for developing and spreading his ideas for health promotion. He completed a master's degree in public health, and to influence other medical professionals, he has published books including What is Adolescence?, which has sold more than 80,000 copies. With respect to his decision to dedicate himself to the field of health, Daniel says, "I always felt myself an entrepreneur, but never was interested in working for my benefit alone or for financial gains. I direct my passion and energy at social action and solidarity."