A Return to the Social Justice Spirit of Alma-Ata

This Publication of the World Health Organization’s (WHO’s) Alma-Ata Declaration, endorsed by representatives of 134 member states in September 1978, is its second appearance in the pages of the American Journal of Public Health (AJPH). The Alma-Ata Declaration’s stirring and comprehensive statement of the ideals of global health justice was first published in March 1979, accompanying American Public Health Association’s resolution # 7816, “Promotion and Expansion of Primary Health Care.” That resolution “fully endorsed the Declaration of Alma-Ata” and acknowledged primary health care as a “right of all people.”^1(p302)

Very soon, however, an editorial in July 1980 referred to “the promises and policies acclaimed with such enthusiasm at Alma-Ata” but wondered whether they would “suffer the same fate as previous well-intentioned declarations.”^2(p681) Another editorial in May 1981 referred to Alma-Ata’s call for “Health for All by the Year 2000” as a slogan and added, “It is not bad as a slogan—but as an objective, is it anything more than wishful thinking?”^3(p459)

In our review of AJPH articles, we found no other explicit mentions of the Alma-Ata Declaration in the 1980s (the Reagan and George H. W. Bush years) and no serious discussion until October 1990, when Milton Roemer and Ruth Roemer published an article strongly supporting the principles of Alma-Ata.⁴ The Roemers responded to critics and cynics and wrote,

Some may cynically say that these legal instruments are mere words, and do not reflect reality. They record social values and policy goals, however, that have been forged from long social struggles—going back at least to the French Revolution and reinforced by . . . post-war movements for national liberation. They affirm principles for social action, they shape political strategies, and they exert, in fact, substantial influence on the features of health systems. National health systems throughout the world have, indeed, been moving in the direction of assuming health service as a human right.^4(p1190)

For this reason, the Roemers were very unhappy that the World Bank had called for curative medical services to be paid for by the people receiving care. In contrast to this call for greater private initiative in national health systems, the Roemers wrote, “The private sector in national health systems has had largely anti-egalitarian effects.”^4(p1191) Indeed, a joint resolution by WHO and the United Nations Children’s Fund (UNICEF) in 1981 had stated that private medical care led to inflated medical expenditures, an excessive cost for foreign pharmaceuticals, and negative influences on medical education and primary care, all of which were directly contrary to the spirit of Alma-Ata.⁵

In the mid-2000s, a small flurry of articles by us and our colleagues Marcos Cueto and Socrates Litsios brought renewed attention to the Alma-Ata Declaration, the background circumstances that led up to it, and its immediate and longer-range reception and impact.^6–10 In our January 2006 article, we called the declaration

an “intersectoral” and multidimensional approach to health and socioeconomic development . . . [that] urged active community participation in health care and health education at every level,^6(p67)

which makes the scant reference to it in AJPH for a quarter century all the more noteworthy, not to say alarming and depressing. AJPH was perhaps in part echoing the fate of the Alma-Ata Declaration at the WHO itself.

When it was first approved, WHO achieved a “kind of jubilation” and “spiritual consensus,” as it was called in a reflective interview with Halfdan Mahler published in the Bulletin of the World Health Organization in 2008.¹¹ Mahler, director general of WHO from 1973 to 1988 and the principal architect and charismatic driving force behind the declaration, described the Alma-Ata conference as having “almost a spiritual atmosphere, not in the religious sense, but in the sense that people wanted to accomplish something great.” He continued,

There is one moment I shall never forget. At the end of the conference, a young African woman physician in beautiful African garb, read out the Declaration of Alma-Ata. Lots of people had tears in their eyes. We never thought we would come that far. That was a sacred moment.^11(p247)

But as Mahler also pointed out, Alma-Ata was received with considerable skepticism by many staff members at WHO. It was likewise resisted and undermined by important outside agencies, even by some United Nations agencies. The biggest disappointment came when UNICEF switched to a “selective” approach to primary care.⁹ The International Monetary Fund and the World Bank played particularly deflective roles in the 1980s. As Mahler said, everything seemed possible in the immediate aftermath of Alma-Ata, until the International Monetary Fund promoted the neoliberal Structural Adjustment Program advocating the privatization of health care services. This undermined the Alma-Ata Declaration and weakened commitment to the primary care strategy Mahler thought essential to it. Some WHO regions kept fighting for this broad “horizontal” strategy but with no support from either the International Monetary Fund or the World Bank. As a result, said Mahler, “we were brought right back to square one.”^11(p747)

Has the WHO returned to the spirit of the Alma-Ata? In 2008, marking its thirtieth anniversary, Director General Margaret Chen started discussions with member states on how to revitalize primary care. Sir Michael Marmot’s Final Report of the Commission on the Social Determinants of Health, also published in 2008, deliberately linked its findings on the need to eliminate global disparities in health to the goals of Alma-Ata.¹² Mahler has diplomatically welcomed these efforts, but it is not entirely clear whether he has in fact fully recovered from his disappointment with WHO. He has expressed particular enthusiasm for a new organization, the People’s Health Movement, which began in 2000 and describes itself as “a global network—bringing together grassroots health activists, and civil society organizations and academic institutions from around the world.” This network subscribes to the “People’s Charter for Health,” a “tool for advocacy and a framework for action” that “endorses the Alma-Ata Declaration, and affirms health as a social, economic and political issue but above all a fundamental human right.” It is quite likely that Mahler senses something of transcendent importance in the People’s Health Movement’s grassroots ties and commitment to social justice.