Wednesday, January 17, 2018

Halfdan Mahler, primary health care, and the warm decade for social justice

This is an expanded version of an article in the (50th) issue of BODHI Times. This is the occasional newsletter of the NGOs BODHI and BODHI Australia which I co-founded in 1989. It is based on several sources, including an excellent open access article by Theodore Brown, Elizabeth Fee and Victoria Stepanova called "Halfdan Mahler: Architect and Defender of the World Health Organization “Health for All by 2000” Declaration of 1978".

A pastor's son, "disease palaces" and the origins of primary health care

Dr Halfdan Mahler, who died in December 2016, was the third Director-General of the World Health Organization (WHO). Brown et al summarise his development: "The youngest child of a Baptist preacher, Mahler chose medicine over preaching." After training in tuberculosis care and prevention "he led the Red Cross campaign against the disease in Ecuador, before joining WHO in 1951. Experience in India convinced him that public health resources in developing countries were biased toward hospital-based medical care and that these priorities had to change."

Socrates Litsios, in a long personal reflection on primary health care and Health for All provides two relevant anecdotes about Mahler, one about the unfair distribution of health resources, the second about the difficulties of reform (see green).

Mahler related the example of a developing country in which health was declared as “a   universal human right” but in which one found, in one province, “80 per cent of the health budget being used to support one teaching hospital, whereas in outlying parts complete coverage is supposed to be achieved by one general purpose dispensary for half a million people.”
"During his work in India, Mahler had become convinced that tuberculosis could be successfully treated with ambulatory (non-hospital based) care: “[we went] with tears in our eyes, to the Minister and we said ‘Madame Minister, now that we have shown this you will have to close down all your tuberculosis hospitals because we need the money in order to do ambulatory kind of treatment’ and she looked at me and said ‘you must be a crazy man, even an elephant would cry over your naivete. How do you think I as a politician can close down the hospitals, you must be mad’.”

Mahler before a Mercator's projection; an unfortunate choice, given his dedication to social justice!
Primary Health Care, Disease Palaces and David Morley

A term reflecting the problem Mahler had perceived is "disease palaces". Popularised (and probably coined) by another Christian, David Morley, this refers to the disproportionate concentration of health resources in one, or perhaps a handful, of fairly elaborate hospitals, in countries which are overwhelmingly poor. The problem is not that a poor nation should not have a halfway decent (or even a good) hospital; it is that the amount of human and financial capital that such a hospital demands leaves little (from the health budget) for basic sanitation, nutrition, health education and other aspects of primary health care. More background about disease palaces is in Morley's book "Paediatric Priorities in Developing Countries". Published in 1973, the same year that Mahler was elected as WHO Director General, it too is a product of what Mahler called “a warm decade for social justice".

I never had the fortune to meet Morley, but I acquired and read his book in 1985, the year I focused on the study of health in what was then still largely called developing countries, including by participating for several months in health care in hospitals and remote rural settings (sometimes mobile) as a medical student in northern Nigeria and eastern Nepal. Another influential book was Maurice King's "Medical Care in Developing Countries". I have met Maurice several times, and in 1992 he became BODHI's public health advisor.

Primary health care (PHC) at its simplest, is "the place of first contact with a national health care system". In some countries, especially those that are poor, this means, for the overwhelming majority, health care that is not "tertiary", that is, not hospital-based. Using this definition, PHC need not be sophisticated, and can be delivered not only by people without university training, but without finishing high school. The most famous example of this were China's "barefoot doctors", whose actual benefit is hard to assess, due to the fog of propaganda.

Primary health care horror stories

Care delivered by barefoot doctors and their equivalent, at no or minimal cost to the patient, is obviously cheaper to provide than via medical schools, pharmacists, or properly trained nurses. In many poor settings, it may be better than fee for service alternatives, even if provided by supposed professionals. When I was more involved with the practical aspects of this topic (between 1985 and 1996) I heard horror stories of the financial abuse of patients (mainly in India and Nepal) by health professionals. 


An example I recall is of people with suspected tuberculosis (TB) travelling to a town for a chest X-ray when a sputum examination (at least in skilled hands) is more accurate and useful, and far cheaper. In low income settings (at least then) a chest X-ray, a test whose cost is modest to most readers, could lead to debt (not to mention the travel and foregone income from not working that day).

Also, as is still fairly common, powerful antibiotics were easily available over the counter (i.e. without a doctor's prescription). The risk of such self medication - especially for TB, which requires months of treatment - even if involving rifampicin - is of developing drug-resistant TB, which is an even more expensive and dangerous public health issue. This problem may be less now, due to DOTS - Directly Observed Treatment (short course), which was introduced to reduce this problem. 

In 1994 I spent one harrowing day seeing about 40 Tibetan refugees, as patients, in a camp in South India. Several were on "third line" anti-TB drugs. These third line drugs are expensive, have a high risk of severe side effects, and are not very effective. Patients get put on these drugs generally because the TB bacteria they harbour have evolved resistance to more effective drugs, because the patient did not take them for long enough (many months). The risk is that such resistant bacteria will cause a primary infection in a patient, such as a child, or even a friend or relative who has previously been cured. If it does, that child could be virtually untreatable, and so will the adult.

The possibility that the successes of PHC are over-stated

Ethical and appropriate care by barely trained community and village health workers cannot be guaranteed, and may well be uncommon, despite its supporters, who may "cherry pick" overlooking failures and exaggerating successes. Such care may be adequate for some health problems, many of which get better without treatment or proper diagnosis. Barefoot or village health care workers can also, in some settings, make simple diagnoses, give advice on hygiene, monitor infant and child growth and treat and prevent conditions such as diarrhoea. They might also apply first aid, administer vaccines, and treat a variety of other conditions. 

On the other hand, especially in very low income settings, many people do have significant underlying health conditions, not just TB, but depression, hypertension (very common in some low income settings, perhaps related to undernutrition in childhood) and chronic parasitic infections such as hookworm or schistosomiasis. (Note: hookworm can be easily treated but re-infection is common, where footwear and hygiene are poor, especially from a lack of toilets). 

I met some community health workers, in India, also in 1994. I felt very sorry for them; they had low status, were young, and appeared completely overwhelmed. There are many limitations to the effectiveness of primary health care but its promise to provide an affordable basic underpinning of health for the poor, especially in rural and remote settings, in ways that hospital based care cannot, was alluring, for a while. My personal experience also made me sceptical about some of the claims in David Morley's book. While the village (in Nigeria) he worked seemed a model of success, I was concerned that this depended too much on his nurse, a European with devotion and skills not easily reproduced and sustained in such settings, though, sometimes, religious faith can provide deep and enduring motivation.

But some primary care groups such as Jamkhed have an excellent reputation. With charismatic and dedicated leadership and support, fairly high quality health care can be provided by people without tertiary education. Such people acquire so many skills over time that they effectively are trained at a tertiary level, at least to the equivalent of a good nurse.

Leading to the "sacred moment" at Alma Ata: back to Mahler

Following the immense global trauma of World War II, so soon after the Depression, WHO and the other UN agencies were bathed in hope.

The struggle between social medicine and technical assistance

However, the inception of WHO (1948) was almost immediately followed by the withdrawal of the Soviets and several other socialist countries, from 1949 to 1957. Fee et al, in a useful recent paper (Nov 2016) in the American Journal of Public Health, trace some of the factors leading to this, especially the sacrifice made by the Soviets in World War II (at least 20 million dead, in comparison the US lost 400,000 troops) compounded by limited assistance to the Soviet Union and its allies, such as via the Marshall Plan. Of course, the US and its allies were both horrified and terrified by Communist beliefs, by its contempt for genuine democracy, by the ruthless purges of dissenters by Stalin and others and by the fact that the USSR was also developing nuclear weapons, as the Cold War progressed.

Some time after the USSR re-joined WHO, Dmitry Venediktov, the Soviet delegate to WHO, and a few others, supported by Mahler, called for a shift in focus by WHO, to better reflect the idealistic post WWII framing of health enshrined in the WHO constitution (see in green).
"Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity".

"the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition".

"governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures ".

Many others in WHO, including Brock Chisholm, the first director-general (a Canadian), hoped that it would still stand by the social medicine principles embodied in its constitution. A key founding member, Andrija Stampar (born in modern Croatia, influenced in medical school in Vienna by Ludwig Teleky’s lectures on social medicine), argued that the WHO should concentrate on 4 principles:

A. social and economic security

B. education
C. nutrition
D. housing.

Taken seriously, a social medicine perspective required questioning the inequality of land ownership in rural areas and the striking inequities, poor housing, misery, and illness in urban areas. However, the United States, WHO's largest funder (at least then) was not interested in this approach and instead promoted the concept of “technical assistance” to the problems of health in what we now call the Global South.

“Technical assistance” conveyed the idea that developing countries were best helped through the transfer of knowledge of science and technology. As many critics have pointed out, this approach bypasses concern with the economic interests and social realities that led to and maintain underdevelopment.
In the 1950s, in its first full decade, WHO had led a massive attempt to eradicate malaria, a clear case of technical assistance. This was inspired by the then recent synthesis of DDT, and the discovery of its almost miraculous insect-killing properties.  It made an enormous difference in India, although most progress there occurred before World War I, which was, actually, the topic of my Master's thesis (at least in the Punjab, which then extended from Delhi right to the Afghan border.)

Fee et al argue that also contributing to the Soviet boycott was a growing conviction on the part of the Soviets and their allies that there were "two dramatically opposing views of public health: that of capitalism and that of communism". This dichotomy persists today.

The election of Mahler: a brief shift towards a social medicine approach by WHO

In 1973, elected WHO director-general, Mahler was able to help channel and shape the political and moral currents of the 1970s. In 1976, early in his directorship, Mahler and WHO accepted a proposal (made by the Soviet Union in 1974) to hold a conference, which was to be called the International Conference on Primary Health Care. In 1977, still led by Mahler, WHO adopted a resolution (WHA30.43) called “Health for All by the Year 2000”.

The conference, which received substantial Soviet support, was held the next year, in Alma Ata, today Almaty, the capital of Kazakhstan, but at that time in the Soviet Union. It was envisaged by Dr. Dmitry Venediktov, then Soviet deputy minister of health, to be on the same scale as the World Population Conference, held in Bucharest in 1974, and attended by more than 1400 people. According to Litsios, Mahler opposed this site, but various alternatives proved unfeasible.

This meeting included the statement that:

“an acceptable level of health for all the people of the world by the year 2000 can be attained.” 
The undermining of Primary Health Care

Soon after the "sacred moment" of Alma-Ata, efforts to weaken Health for All began, (and the broad view of primary health care) weakened, as neoliberalism increased in power. I, with Sharon Friel, also published on this in 2006) - it's also open access, in PLoS Med. We wrote:

"All social movements and scientific disciplines are subject to powerful institutional and natural forces that shape their social, economic, political, and environmental milieu .. like the health promotion movement, WHO is also subject to larger forces. Since Alma Ata, the rhetoric, aspiration, influence, and—arguably—the achievement of WHO has diminished, coincident with a decline in many public goods."

Mario Cuteo, in a 2005 editorial in the Bulletin of WHO also sheds light: "In its more radical version, the complete reform of public health structures and the promotion of major social changes were envisaged, with primary care as the new centre of health systems. In contrast, according to an instrumental interpretation, it was merely an entry point, a temporary relief or an extension of services to underserved areas. The latter interpretation could not avoid being perceived as second-class care, “poor” medicine for poor people."

Cuts to the WHO budget: the counter revolution, led by the US under President Reagan

Brown et al note: "Major donor nations, such as the UK and the US froze contributions to the WHO budget. Then, the Reagan administration decided to pay only 20% of its assessed contributions to all United Nations agencies. In 1979, the Rockefeller Foundation sponsored a small conference included representatives of the World Bank, the US Agency for International Development, the Rockefeller Foundation, and the Ford Foundation, which formulated an alternative “selective primary health care” agenda, which differed sharply from the agenda and spirit of Alma-Ata. Mahler’s principal lieutenant in the battle for Alma-Ata was Ken Newell, a New Zealander, whose edited book Health by the People was influential. 

Newell called these efforts a “counter-revolution.” The World Bank, the main international donor for health development, adopted a neoliberal policy of privatizing health services in the 1980s, further undercutting Alma Ata."

Also excellent and relevant in understanding the decline in the vision of Dr Mahler is the book by David Sanders and David Werner "The Politics of Primary Health Care and Child Survival". See this book review by Claudia Shuftan.

Mahler making enemies

Mahler alienated many people. Another anecdote from Litsios is that, when Director General elect, Mahler supposedly advised a “very powerful president of a developing country,” who had asked Mahler what he could do to develop a health care system (which Mahler told him he did not have) as follows: “I think the first step is to close the medical schools for two years. Then we can discuss what the medical schools were supposed to do, because they really constitute the main focus of resistance to change”. 

Back to the future: world health dominance by corporate-derived foundations 

Technical assistance such as to eradicate malaria was revived, but not by WHO in the 2000s. It is again likely to fail, this time in part because of increasing resistance to insecticides used to impregnate bednets, by mosquitoes, rather than resistance to DDT, the breathrough seen as miraculous in the 1950s. 

Mahler and Family Planning

After retiring from WHO in 1988, Mahler became Director of International Planned Parenthood Federation until 1995. Throughout his career, Mahler emphasised the role of women in promoting health. “Women are the raw material for development”, Worning remembers him saying. The economic and health benefits of spacing children has long been one of my own main pleas. I have written dozens of papers about this, but with little obvious result! (e.g. Reflections on human carrying capacity)

Mahler's final plea

Thirty years after the Alma-Ata Declaration, Mahler told the World Health Assembly in 2008: “To make real progress, we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactorial causation of disease have, for a long time, called attention to the association between health problems of great importance to man and social, economic, and other environmental factors.”

Looking forward

Although the Sustainable Development Goals may seem as hopeful and aspirational as Health for All, they have virtually no chance of succeeding. In fact, it is all too plausible that we are headed for a new dark age. The presidency of Donald Trump is but one manifestation of deepening inequality. Ugo Bardi, a member of the Club of Rome, has noted that as cheap energy declines, slavery is returning.  Famines are returning and "regional overload" is obvious in a growing number of locations.

A great awakening is needed. We need new leaders such as Jeremy Corbyn, Bernie Sanders (or maybe Elizabeth Warren) - but not neoliberal Oprah Winfrey. We need more vegetarianism and technological miracles. We need more courage in academia and also in the development movement, who are either blind or self-censoring about high rates of population growth in poor countries. We will need a lot of luck, because leadership such as from Mahler is now very hard to find.