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Is the UN dream to achieve optimum health for all the people of the world a pipe dream? Revisiting the Alma-Ata Declaration

Opeyemi Akindele

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Although the MDGs (with their deadline closing in on us already) were formulated in 2000, the year 2000 was not the first time that countries of the world would set ambitious goals. From 6-12th September 1978, the International Conference on Primary Health Care was held in the defunct USSR’s Alma-Ata where 10 declarations which put health on the political and economic agenda were made.

At the historic conference, apart from the fact that the issue of health was made a political/economic one; health was given a comprehensive definition as contained in the first Declaration of Alma-Ata. Departing from the traditional biomedical model, health was defined as not just the absence of disease but also psychosocial and economic wellness.

Having given a broad definition of health, the conference then set an ambitious but vague goal in its fifth declaration: “…the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life.”

For me, expecting every one of the billions of people in the world living in widely varying economic, political and socio-cultural contexts to attain an optimal level of all-round, comprehensive health in just a little over two decades (1978-2000) was quite an ambition. Moreover, the set goal was vague in the sense that the Alma-Ata Declaration did not precisely pin down what things constitute ‘to lead a socially and economically productive life’.

Furthermore, even if all the human and financial resources required by every country of the world to achieve the lofty goal were available at the time, unanticipated global/regional events following the historic conference of 1978 would still have caused enormous humanitarian crisis as to impede the realisation of “health for all by 2000″ nonetheless.

Let us consider the issue of regional wars in the years following the Alma-Ata conference. It is clear that those who participated in and drafted the Alma-Ata covenant did not factor in the problems that comes with war: economic retardation/stagnation, poor vaccination coverage, poverty, long-term psychological disorders, disease outbreak etc. The Shah revolution of 1979 which toppled the Iranian monarchy was soon followed by Iraq’s invasion of oil-rich Kuwait. That also was followed by the military involvement of the United States and her allies in the Iraqi war and the attendant arms proliferation in the region.

Combined with the activities of Somali pirates, the war in the Middle East affected the oil market and the price went up. Sudan was still fighting a bitter civil war inflicting deaths and deformities on civilian population. In Europe, political and ethnic tensions continued to rise within the socialist USSR leading to its eventual dissolution under the leadership of Mikhail Gobachev on 25 December, 1991. Brutal wars and ethnic cleansing soon broke out among countries that emerged from the erstwhile USSR, notably Yugoslavia. All these wars and turmoil, and the host of associated problems clearly set back the realisation of the Alma-Ata agenda.

Secondly, HIV and the epidemiological predicaments it presents was not anticipated. Conspiracy theory aside, it was not possible for anyone or any country to know that HIV would emerge on the global stage in 1981, not to speak of making robust preparation to contain it. It is unequivocal that HIV greatly impacted the realisation of “health for all by 2000″ in a negative way. I will illustrate this by taking a quick look at Africa.

WHO statistics show that sub-Sahara Africa’s share of maternal mortality rose from 23% in 1980 to about 52% (which is more than double)by the year 2008. HIV/AIDS accounts for a significant proportion of maternal mortality (creating more orphans and childhood poverty etc.) in Africa. For instance, while South Africa reduced its 1980 maternal mortality ratio (MMR) by about 40% to 121 per 100,000 live births by 1990, the figure rose to about 155 by the year 2000, and further to about 237 by 2008, according to a Bill & Melinda Gates-funded research conducted by Hogan Margeret and colleagues (published in Lancet 2010). The researchers noted: “In the absence of HIV, progress in sub-Saharan Africa in reducing the MMR would have been much more extensive than we recorded.”

That “all peoples of the world by the year 2000″ did not attain the desired level of health is now a fact of history. Subsequently, the Millennium Declaration (from which the MDGs were later developed) was adopted to replace the failed Alma-Ata Declaration. While a lot more have gone into the actualisation of the MDGs and commendable achievements have been recorded more than the Alma-Ata era; it is however obvious that the Millennium Declaration would not also be declared as a success by the end of 2015 when the stock would be taken. Many countries, especially in sub-Sahara Africa would not meet most of the targets as they are out of track.

Consequently, my submission is that rather than aiming for some idealistic targets for global or national health, the United Nations and each member country should focus on fulfilling the imperatives of human development. A huge difference exists between merely attaining the MDGs and actually fulfilling the imperatives of human development. For instance, even if a sub-Saharan African country like Eritrea were to achieve the maternal mortality target (reduce maternal deaths by 75% of 1990 level); the tiny East African country would still be left with with 323 maternal deaths per 100,000 live births. Yet that “remarkable success” leaves it with a figure which is 46 times the maternal deaths in Canada, 27 times the United States’ and 32 times the average for Western Europe 35 years ago! On the other hand, it would be preposterous to say that the UK has “failed” to achieve developmental goals even though it has maintained a stagnant MMR of 8 since 1990 (two points down from 10 in 1980).

Therefore, without real socioeconomic development and political stability, it is practically impossible for many countries (especially in the developing world) to sustain and improve on their achievements, even if they were to meet the MDGs target. Universal Health Coverage, political stability (not necessarily Western-styled democracy), good governance, women education, economic growth and empowerment as well as equitable and fair international trade policies are the issues that should be pursued. It is these that would naturally improve the quality of life of the people of any country. More donor drugs, more expatriates medical personnel and the idea of dragging every country along to attain the same targets are not sustainable.

As I close this essay, it is perhaps instructive to refer to Vandemoortele, a past UN official who played a key role in formulating the MDGs. According to him, the MDGs were not intended to serve as a strict benchmark for every country to attain to by 2015; but rather as an impetus for “all countries to strive for accelerated human development”.

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