The Origins of Holistic Primary Health Care

The Barefoot Doctors

Holistic Primary Health Care is not a new or novel idea, but rather traces its roots to the very core of 20th century international health care policy. The story begins on the eve of China's cultural revolution in 1949 when the entering government found itself facing a health care crisis: for every 10 000 people there was only one registered and qualified medical doctor. China's unique response to this was the now famous Barefoot Doctors. Whilst incorporating Traditional Chinese Medicine the general focus was on basic hygiene, preventative medicine, family planning and simple treatments for common ailments, and ultimately came to accommodate 80% of China's population with a massive 1.8 million community based health care workers. The system was highly praised by the World Bank and World Health Organisation at the time and was considered to be a viable alternative to the western hospital based system.

A Crumbling Health Care Model

At this point in time, with The World Health Organisation and UNICEF having just been formed out of the ruins of post WW2 Europe, international development and health care policies were under serious criticism from many respected authorities, as the previous colonial era approaches came under close scrutiny in the light of 20th century changes in ideology. WHO's constitution had already radically redefined health to be more than simply the absence of disease, prompting the then president of WHO Mr M. Mahler to state "The scientific and technological structures of public health are crumbling". A radical sense of change was already in the air, which was only heightened by growing concerns that the hospital based and strongly disease oriented system was not only failing to improve the health of developing nations, but was also failing to adequately meet the needs of the first world nations that had implemented it to begin with. Somewhat controversially, the president of the WHO even likened the current technologically oriented system to the classic Frankenstein myth of the sorcerer’s apprentice, as it was deemed to be out of social control. Riding on the international recognition of the success of Barefoot Doctors model, the Chinese delegate to the WHO then suggested an international conference to discuss the issue.

The Alma Ata Declaration

The result, after much debate, was the Alma Ata Conference of 1978 where the principles of Primary Health Care were formally defined: 3000 delegates from 134 nations and 67 International NGO's made this the biggest convergence of world leaders in history, and yet somehow most health care providers today have never even heard its name. Three key ideas permeate the declaration of Alma Ata: a preference for non-technological interventions (such as nutrition and sanitation), opposition to medical elitism through genuine community involvement in health care strategies, and the notion that health care was inseparable from socio-economic development. Indeed, Primary Health Care as envisioned at Alma Ata had very strong socio-political implications. It specifically stated that we must address the underlying social, economic, and political causes of poor health if WHO's goal of "Health for All" was to be attained by 2000. It strongly emphasised disease prevention, health promotion, community participation, self-reliance, and intersectoral collaboration whilst, like the Lalonde Report before it, acknowledging that poverty, social unrest, the environment, and a lack of basic hygiene and nutrition contribute more significantly to poor health status than medical intervention alone.

"Selective" Primary Health care

Despite The Alma Ata Declaration being universally accepted alongside other great humanitarian declarations after it was formally endorsed at the 32nd World Health Assembly, it very quickly came under attack from the corporate sector and medical right wing, and in less than twelve months an alternative system had been proposed. The Rockefeller Conference of 1979 was held to address "disturbing signs of declining interest in population issues" and was attended by a much smaller list of delegates headed by industry leaders such as the President of the Ford Foundation, and the President of the World Bank and former Secretary for US Defense, Robert McNamara. It was here that an interim model known as "Selective Primary Health Care" was formerly endorsed. Rather than broad reaching policies that addressed health through social justice and economic equity, the worst diseases would be selectively targeted according to their prevalence, morbidity, mortality, and feasibility of control (including efficacy and cost).

Four basic services were then to be provided in International Aid; this was defined as the G.O.B.I. approach. Rather than implement costly interventions to eradicate world hunger Growth monitoring would be implemented, to see which infants were worst affected. Rather than solve basic sanitation issues that resulted in many dying of dehydration from dysentery and diarrhea, Oral rehydration sachets would be distributed. Rather than engage in long term programs of economic development and education, Breast feeding would be promoted to increase birth intervals, and finally, rather than actively promoting health as defined by Alma Ata, specific diseases would be 'selectively' targeted by Immunisation campaigns.

The underlying philosophy of "Selective" Primary Health Care, was the system WHO and UNICEF had originally attempted to change, but has since informed most domestic and international health care policies around the world. This system focuses on selective diseases, rather than promoting health, it prefers technological interventions to education and prevention, it is the domain of the medical elite rather than the local community, and its costs are steadily escalating rather than decreasing. The international gold standard established at Alma Ata, which was very much in the spirit of the Universal Declaration of Human Rights, has been largely abandoned and with it the full recognition of health as an inalienable right of life that must not be neglected nor compromised by reduced "selective" measures. Despite the very worthy goals outlined it would seem that even the esteemed Millennium Declaration has adopted a selective model for future programs. It is important to note that countries such as Cuba that rejected the Selective approach and attempted to enact the principles have achieved remarkable gains in their population health. Despite a radically smaller budget and years of crippling trade embargos the Cuban Infant Mortality Rate was roughly half that of Washington DC in 1997.

Holistic Primary Health Care

In 2008, to commemorate the 30th anniversary of the Alma Ata Declaration, One Health Organisation has defined the principles of Holistic Primary health Care in light of the lessons learned over the last three decades under the "interim" approach of Selective Primary Health Care. In doing so we have drawn upon not only the Alma Ata Declaration, but also the WHO Constitution, The Universal Declaration of Human Rights, the Geneva Convention, The Ottawa Charter, the Hippocratic Oath, The Lalonde Report and the vast array of wisdom contained in traditional medical systems from around the world. This is due to our firm conviction that Primary Health care was never really given a trial, and that it is even more necessary today than in 1978. Since the original declaration the west has learnt that economic development does not safe guard health, we have learnt that high immunisation rates alone do not guarantee low infant mortality and morbidity, we have learnt genuine community involvement is also necessary in developed countries and urban environments, we have learnt that natural systems have a finely based ecological balance and must be intervened with gently and cautiously to avoid dangerous and unwanted repercussions, we have learnt that affluence and industrialisation brings its own challenges to health, and finally, we have learnt the true cost of failing to prioritise this most inalienable right of life with spiraling health care costs.

In closing, the leading WHO delegate to Alma Ata opened the 1978 conference with the following daring challenges that we would like to restate to you now:

"Are you ready to introduce, radical changes in the existing health delivery system so that it properly supports Holistic Primary Health Care as the overriding health priority?"

"Are you ready to fight the political and technical battles required to overcome any social and economic obstacles and professional resistance to the universal introduction of Holistic Primary Health Care?"

To which we would add: "Are you ready to end the war on disease, and begin to positively promote a state of health as an inalienable right of life?"

If so, then endorse the principles of Holistic Primary Health Care, and begin to implement them in your local community now!

In order to more fully understand the principles of HPHC it is recommend that you familiarise yourself with the following relevant international documents:

Constitution of WHO

Universal Declaration of Human Rights

Declaration of Alma Ata

The Ottawa Charter

The Hippocratic Oath

World Medical Association International Code of Medical Ethics