Halfdan Mahler: Architect and Defender of the World Health Organization “Health for All by 2000” Declaration of 1978

The adoption of the Declaration of Alma-Ata in September 1978 was one of the shining moments in public health history. It was the occasion for the World Health Organization (WHO), the United Nations Children’s Fund, and the 134 signatory nations to declare the goal of “Health for All by 2000” along with strong associated commitments to “development in the spirit of social justice” and to “essential health care” that was “universally accessible” as “an integral part of each country’s health system” and of “the overall social and economic development of the community.” Health, according to the declaration, was “a fundamental human right,” and the attainment of its highest level was “a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector.”¹

Secretary-General Halfdan Mahler of the WHO was the charismatic driving force behind the declaration. Mahler was born in Denmark, the youngest child of a Danish Baptist preacher. Mahler chose medicine over preaching and obtained his medical degree from the University of Copenhagen in 1948. After specialized training in tuberculosis, he led the Red Cross campaign against the disease in Ecuador and then joined the WHO in 1951. His experience with the WHO’s campaign against tuberculosis in India convinced him that public health resources in developing countries were excessively biased toward hospital-based medical care and that these priorities had to change.² In 1970, he was appointed assistant director-general of WHO and in 1973, elected director-general.

By 1978 Mahler was able to advance his health priorities by channeling and shaping the political and moral currents of the 1970s, which he later called “a warm decade for social justice.”³ The 1970s saw the powerful political expression of developing nations in the form of the “new international economic order,” which demanded fairer terms of trade in the context of global social justice.⁴ These forces culminated in Alma-Ata as a “sacred moment.”³

Very soon after the formal declaration at Alma-Ata, however, efforts to reshape or even nullify it were under way. Major donor nations, such as the United Kingdom and the United States, froze contributions to the WHO budget. A few years later, 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 at its Bellagio conference center in Italy.⁵ The Bellagio conference included representatives of the World Bank, the US Agency for International Development, the Rockefeller Foundation, and the Ford Foundation, and they formulated an alternative “selective primary health care” agenda, which differed sharply from the agenda and spirit of Alma-Ata. Selective primary health care focused on specific low-cost technical interventions—such as vaccinations and oral rehydration—to address common diseases in developing countries.⁵ A few years later, Mahler’s principal lieutenant in the battle for Alma-Ata, Kenneth W. Newell, called these efforts a “counter-revolution.”⁶ The World Bank, the main international donor for health development, adopted a neoliberal policy of privatizing health services in the 1980s, thus further undercutting the Alma-Ata ideals.

Mahler tried on many occasions to defend the principles of Alma-Ata. In 2008, on the 30th anniversary of the declaration, he addressed the World Health Assembly and declared:

“Unless we all become partisans in renewed local and global battles for social and economic equity in the spirit of distributive justice, we shall indeed betray the future of our children and grandchildren. . . . 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.”⁷

In his recent public appearances, Mahler remained faithful to his social justice approach to health and has served as an idol for health activists and civil society organizations such as the People’s Health Movement. Some three decades earlier, in 1981, he published a striking essay in the World Health Forum, “The Meaning of ‘Health for All by the Year 2000,’” in which he defended the main principles of Alma-Ata, which were already under attack.⁸ This reaffirmation and defense is excerpted here.