Promises to keep

With governments persistently defaulting on their commitments, purposeful intervention through popular mobilisation is needed to achieve health care goals. Some highlights from the People's Health Assembly 2000 held in Dhaka.

TO see the people who remain unseen, to hear the voices of the unheard. Token acknowledgments of the need to provide a platform for the growing mass of those dispossessed by the onward march of globalisation have reverberated through international confer ences for at least a decade. Rarely have they achieved the resonance they did at the People's Health Assembly 2000.

PHA 2000, which was held in Dhaka between December 4 and 8, grew out of a sense of despair at the meaningless ritual that the World Health Organisation's annual conclaves have become. Ever since the 1978 Alma Ata declaration adopted 'Health for All by 20 00' as an eminently achievable goal, the WHO has become a mute spectator to global processes that have negated every prospect of progress towards that objective.

In the late-1980s, the top management of the WHO - perturbed by the growing divergence between the realities of the global order and the promise of Alma Ata - thought up a creative response. It challenged the growing sector of non-governmental organisati ons involved in health care and education to take the initiative in pressuring governments across the globe to attend to their basic obligations.

Among those who were party to this early initiative was Dr. Zafrullah Chow-dhury, the Bangladeshi surgeon whose contributions towards an alternative health paradigm are today embodied in the nation-wide institutional network of the Ganashasthaya Kendra ( G.K.). Appropriately, G.K. offered to host the first global conference of activist groups involved in health. That promise materialised in the shape of PHA 2000 well over a decade after it was made. The need to bring on board a variety of participants, a ll with their distinct agendas, was responsible for the delay, explains Chowdhury. And in this intervening period, the WHO drifted further away from any residual sense of commitment to the goals of Alma Ata.

The format of PHA 2000 was dependent on a number of parallel sessions at which the whole gamut of issues connected to health were discussed. These were reported back to the plenary session and leavened by case studies of individuals trapped in situations where they were denied access to basic health care facilities.

In the welter of stories that were presented, one was especially significant in the instant associations it evoked with dilemmas at a larger level. A Nepalese health worker narrated the excruciatingly typical kind of problem faced by the landless poor in her country, trapped in bondage to their landlords by trifling debts incurred generations in the past. The story seemed easily to make the transition from the particular to the general, to represent in microcosm the difficulties that the poor countries face in providing a better standard of life for their people.

The Alma Ata declaration was one among a number of initiatives that were taken in the 1970s by the poorer countries to bring their specific concerns to global attention. The goal of "health for all" was in fact recognised as part of the larger task of ac hieving a "New International Economic Order". The Alma Ata declaration made this specific correlation when it argued in its third paragraph that "economic and social development based on a New International Economic Order is of basic importance to the fu llest attainment of health for all and to the reduction of the gap between the health status of the developed and developing countries". And there was an immediate assertion of the reciprocal reinforcement between health and economic well-being: "The pro motion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace".

Seemingly unknown to the authors of the Alma Ata declaration, the Third World debt bomb was rapidly building its explosive force even as these fine words were being written. And when the bomb burst in 1982, it effectively meant the abandonment of all the commitments that had been articulated through the 1970s.

American activist and educationist David Werner, with years of experience in Latin America and several landmark books behind him, identifies the "McDonaldisation of health care" as the key factor underlying the transition from "health for all" to "health for none''. There were, he argues, three crucial landmarks in this ''steady deterioration''. The first came in the decision to abandon comprehensive primary health care in favour of a targeted approach. This meant, as he puts it, the "depoliticisation" of the health movement. The Alma Ata declaration, Werner argues, really sought "social and structural change in the direction of equity as a major element in achieving health for all". The selective approach, in contrast, "was an attempt to use a few cho sen technologies to improve statistics in health while maintaining all the social inequalities of the status quo".

A second assault came with the adoption under duress of structural adjustment policies in the Third World. Beginning in the 1980s, these policies were a direct response to the debt crisis. They meant the privatisation and commercialisation of health care and the erosion of the autonomy of families and communities.

In Werner's narration of events the final assault came in 1994 when the World Bank took up, in its World Development Report, the theme of "investing in health" and began a phase of activism in the health sector.

Werner's reading reflects years of experience and an activist orientation that remains undiminished by the creeping disability of motor neuron disease. But his reservations about the World Bank's participation in the health sector were shared by virtuall y all the participants at the PHA. Expectedly, the most contentious session in Dhaka was that of December 6, when Richard Lee Skolnik, a director of the World Bank in the health division, made an effort to articulate his institution's commitments in the area. Sections within the organising committee of PHA 2000 claimed that the session had been scheduled without their concurrence and resolved to agitate against the presence of the World Bank. An uneasy compromise was later crafted, permitting a token de monstration before Skolnik would present his case and subject himself to the minute scrutiny of the assembly. But the World Bank official's rather brash effort to assume a posture of superior wisdom rankled with the assembly and led to a prolonged disrup tion of his speech.

The burden of Skolnik's presentation, when it was finally made, was that neither the World Bank nor the structural adjustment policies it had sponsored were responsible for declining health standards in the developing countries. Rather, the blame was ful ly to be borne by the misplaced priorities of national governments, which continued to squander scarce resources in unproductive subsidies for the rich. Governments needed both to spend more and spend more efficiently in order to improve health standards . And the World Bank would continue to remain a major player in improving health services in the developing countries.

A panel of respondents proceeded then to dissect the World Bank case. The commentator and activist from the Philippines, Antonio Tujan, pointed out that the Bank could not evade culpability for the growing burden of Third World debt, which pre-empted a s ubstantial part of national resources in servicing loans that had effectively been repaid several times over. David Legge, an Australian political economist, pointed to the cruel ironies of the Bank's prescriptions of "wealth through growth", which could be reduced to the prescription that the poor should suffer now for better health in the distant future. The Bank, said Legge, could not plead that its belated discovery of poverty and disease absolved it of the responsibility for all the damaging conseq uences of structural adjustment. It had to be held accountable for the consequences of the first phase of structural adjustment policies, which the second phase was trying rather reluctantly to correct.

The South African physician David Sanders drew attention to the negative impact of the excessive "medicalisation" of health services. A case in point is oral rehydration therapy (ORT), which has been transformed from an easily accessible life-saving meth od into an expensive and inefficacious commodity under the tutelage of multilateral aid agencies. Once an integral part of a poor family's basket of nutrition, ORT became an economic burden that competed with the budget for food. The consequence has been that in order to survive a potentially fatal attack of diarrhoea, the child today has perhaps to eat less, rendering him or her vulnerable again to the cycle of disease.

A CONSPICUOUSLY upbeat note was struck by the Cuban delegation, which breathed defiance at the brutal economic blockade that the United States has imposed on the island republic. Hafdan Mahler, a former Director-General of the WHO and one of the architec ts of the Alma Ata declaration, spoke of Cuba as an appropriate place for a "pilgrimage" by activists keen to study how positive synergies could be established among all the sectors that have a bearing on health.

When the issue of strategy was discussed, there was inevitably a focus on political action to halt the precipitate descent into economic misery and ill-health. Many of the NGOs that participated in the Dhaka event are autonomous centres of influence in t heir national contexts, whether as providers of health services or as policy analysts. There is a very real danger, though, that some of the NGOs, particularly from the poorer countries, could fall into the potentially fatal embrace of the World Bank and other multilateral agencies. For this reason, the People's Health Charter that was crafted after five days of intense debate and adopted by unanimous acclaim, speaks of enforcing accountability on both the government sector and the NGO sector.

There was no getting away from the fact, though, that popular mobilisation was an absolute essential. "The idea of Alma Ata did not come from the governments," says Maria Zuniga, a veteran health activist from Nicaragua. Rather, it came from the people a nd the governments just assented because it seemed there was nothing to lose in abstract formulations of distant goals. The story since has been one of how governments have persistently defaulted on these commitments, since popular movements have been de void of the means to hold them to account.

Armed with a charter for political action, the PHA could presumably go forward to exert its influence in national and global forums. Certain delegates, notably from India and the African continent, raised the issue of constituting a core group within the PHA to deliberate on future action and initiate a course of purposeful intervention. The need to provide adequate representation to the different shades of political opinion that were seen at Dhaka was accepted with little dissent. But the practical det ails remain to be worked out. And on that would depend the future efficacy of the PHA as a forum working for the benefit of the poor.