Dr Halfdan Mahler, three-time Director General of the World Health Organisation, passed away in Geneva on December 14. The current generation of health activists and public health professionals may perhaps struggle to fathom the deep impact Mahler’s visionary approach had on public health. Credited with steering the Alma Ata Declaration on Primary Health Care in 1978 and the attendant call for Health for All by 2000 AD, Mahler squarely placed health in the domain of the public.
Mahler was a Danish physician who joined the WHO in 1951 and went on to be serve as the organisation’s Director General between 1973 and 1988. Before moving to the organisation’s headquarters in Geneva, he worked for a decade in India in the National Tuberculosis programme. Dr D Banerji, one of the doyens of public health in India, would later comment on Mahler’s stint in India as “one of the most outstanding instances of international cooperation, involving intense interaction between the nationals and their international counterparts as equal members in both disciplinary and interdisciplinary contexts”.
When Mahler moved to Geneva in 1962, the WHO was very different from the body it now is and was still recognised as the leader in international health. Mahler’s later dissatisfaction with the demise of the WHO’s leading role – and the usurpation of this role by agencies such as the World Bank and private foundations such as the Gates Foundation – was clear in his address to the 61st World Health Assembly in 2008.
“Most importantly, the very first constitutional function of WHO reads, ‘To act as the directing and coordinating authority on international health work,’” he said. “Please do note that the Constitution says ‘the’ and not ‘a’ directing and coordinating authority.”
The 1960s and 1970s were the Cold War period, with the Soviet Union and the United States vying with each other to assume leadership. It was also the era of disease control, when health systems were primarily designed to control infectious diseases through what were known as vertical programmes.
Mahler and some of his colleagues sensed the dissatisfaction across continents with top-down systems that had little place for local communities and in most low- and middle-income countries were driven by western perceptions and priorities. Working with colleagues in the WHO and in tandem with Henry Labouisse, who was executive director of UNICEF, Mahler was responsible for crafting the primary healthcare approach to healthcare services.
Mahler and his colleagues adroitly negotiated contradictory perceptions in the bipolar globe and produced the Declaration on Primary Health Care issued in 1978 by 134 member states of the WHO gathered in the former Kazakh capital Alma-Ata. The Primary Health Care approach was both elegant in its simplicity and startlingly bold in the sweep of its vision. At its core the approach stressed the importance of pledging a major portion of resources at the primary level, where people live, work and fall ill. The Declaration defined primary healthcare as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”.
Later in life, Mahler would lament the dilution of the vision of the primary healthcare approach as a consequence of the imposition of conservative economic policies by international agencies such as the World Bank and the IMF. “When people are mere pawns in an economic and profit growth game, that game is mostly lost for the underprivileged,” he commented.
However, he remained optimistic about the intellectual and visionary power of the approach. He began his address in 2008 to the World Health Assembly by quoting Milan Kundera: “The struggle against human oppression is the struggle between memory and forgetfulness.” He ended his address by saying, “And so, being an inveterate optimist I do believe that the struggle between memory and forgetfulness can be won in favour of the Alma-Ata Health for All Vision and its related Primary Health Care Strategy.”
Mahler remained a champion of primary health care and of people’s movements striving to make its vision a reality. Many Indian activists would recollect his towering presence at the National Health Assembly in Kolkata in 2000 and subsequently in Dhaka at the First People’s Health Assembly – the precursor to the formation of the global People’s Health Movement.
“People’s Health Movement is the only movement that understands and works towards comprehensive Primary Health Care unlike other civil society networks who focus on specific diseases,” he said in an interview given to the People’s Health Movement in 2007.
In Mahler’s demise, the movement for creating a just and equitable society where health is not a commodity but a universal right, has lost a great thinker, a dear friend and comrade in arms. Today, when the WHO has been reduced to a mere pawn by rich countries who seek to starve it of resources and favour their own commercial interests, and by private corporations and foundations, it is worth recollecting that the WHO’s constitution says. “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.”
The writer is Associate Global Coordinator of the People’s Health Movement.