Savar, Bangladesh -- More than two decades ago, the nations of the world issued a call for "Health for all the people of the world by the year 2000," in the Alma Alta Declaration, the product of a World Health Organization-UNICEF conference.
In 1978, at the time of the Declaration, that goal seemed achievable. There was serious talk of a New International Economic Order, to begin to remedy the wealth and technology gap between the global North and South. Primary healthcare was held "the key to attaining th[e] target" of health for all.
Now, with 2000 upon us, it is evident that the world failed to turn the vision into reality.
Earlier this month, approximately 1,500 public health activists from 93 countries gathered at the spirited and historic People's Health Assembly (PHA) in Bangladesh to assess this state of affairs, and to map the way forward so that health for all is in fact achieved.
The emerging PHA diagnosis, which focused primarily on healthcare failures in developing countries, was multifaceted: Governments have failed to invest sufficient resources and empower localities to assure adequate nutrition, clean water, maternal and child health care and other components of primary health care. This governmental failure is rooted in many internal problems, but especially reflects the budgetary and policy squeeze imposed by the International Monetary Fund and the World Bank and foreign debt repayments, as well as the World Trade Organization. Meanwhile, multinational corporations are pushing a privatization agenda for healthcare which removes control of crucial health decisions and delivery systems from the public sphere, where it is subject to popular influence, and often removes access to healthcare altogether from poor people.
The delegates had an opportunity to passionately denounce the institutions of corporate globalization when a World Bank representative attended a session labeled "The World Bank Faces the People." Led by the Indian delegation, PHA attendees hooted and booed the Bank, chanting "Down, Down, World Bank, Down Down." They spoke with raw emotion of Bank projects which have displaced people from longstanding communities, destabilizing both societies and public health, and of Bank lending programs that pushed national healthcare systems in the direction of a corporate-dominated model.
Primary healthcare remains a top priority, the PHA concluded, but it was unlikely to be achieved broadly in the absence of fundamental transformations in the global political economy.
A "People's Charter for Health" issued by the PHA (see http://www.pha2000.org/pch8Dec.htm) asserted that health is a human right and that "health and human rights should prevail over economic and political concerns," and it called for the provision of "universal and comprehensive primary health care, irrespective of people's ability to pay."
But the Charter also called for the cancellation of the Third World debt, major changes at the IMF, World Bank and WTO, effective regulation to control the activities of multinational corporations and controls on speculative international capital flows. It also includes provisions on the environment, war and violence.
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The imperative of achieving macro-level transformations did not depress the delegates. There were more community health workers than professional policy advocates at the conference, and delegates from developing countries vastly outnumbered those from industrialized nations.
These delegates were able to relate their own successes to illustrate what can be achieved, despite enormous obstacles, with determination and organization.
A. Chintamani, a health worker from a low caste in India, explained how she learned to wear shoes to prevent hookworm -- despite an expectation that people in her caste would go barefooted -- and then became empowered to deliver care even to upper caste persons, who were forced to turn to her, because she offered the best available care.
Delegates from Cuba related the island's stunning public health achievements -- with many national health indicators, such as infant mortality levels, comparable to those in the United States -- in the face of the U.S. trade embargo. The international audience cheered long and loud for the Cuban delegates -- in appreciation of Cuba's accomplishments and in solidarity for its resistance to U.S. aggression.
Most heartening, perhaps, was the example provided by the PHA hosts. The meeting was held on the campus of Gonoshasthaya Kendra (GK), a Bangladesh NGO that has constructed a hospital, university and generic drug factory. Putting the concept of primary healthcare into effect, GK has trained countless health workers -- mostly women -- to raise health standards in surrounding villages. It leads the way in supplying care in the wake of floods and other national emergencies in Bangladesh. GK pharmaceuticals, and its support for Bangladesh's progressive national drug program -- which has weathered relentless attacks from multinational drug firms -- have made essential medicines available to consumers throughout the country.
What GK and other success stories conveyed at the PHA reveal is that it is not for lack of resources or knowledge that the world has failed to deliver on the promise of the Alma Alta declaration.
What is lacking is political will, from the village to international level.
"While governments have the primary responsibility for promoting a more equitable approach to health and human rights," the People's Health Charter concludes, it will require people's organizations to force them to meet this responsibility.