This next lecture is going to be a very special experience for you.
This is a lecture that Karl Taylor made several years before his death.
You've heard me mention Karl from time to time already at various points in this
course. And you'll be hearing more about him as
we go forward as well. The lecture that you'll be hearing now,
Carl recorded several years before his death, is an introductory lecture in a
course that is on the website on the OpenCourseWare that we have here at Johns
Hopkins called Case Studies in Primary Health Care.
But the title of this lecture is called Roots of Primary Health Care: The Path
towards Alma Ata. And, you'll hear some, similarities in
what Carl is talking about, to what I've already presented to you, but it's
slightly different. There'll be some different nuances, and
different emphasis, and That I think he'll be great, for you to hear these
ideas as, Carl himself, presented them to his students.
Enjoy. [MUSIC] [MUSIC] Hello, this is Carl
Taylor. I'm here talking, for a course that I've
been teaching now for several years at Johns Hopkins, called Case studies in
primary health care. The core started about 1987, when I came
back from China, where I'd been UNICEF representative, and the students asked.
Did I start a course to tell, what we learned when working, for UNICEF in
China. And as I always said, it was a great
opportunity to, do that, to be responsible for the whole China program.
At a time when i have been teaching international health and now i have a
chance to actually do it. And this topic, that we are opening,what
is primary health care, goes out of the involvement that, That we have had,during
the nineteen seventy's, to actually work actually work together with the people in
WHO and UNICEF for the world conference on primary health care and that, And I
was one of the two consultants who drafted the basic documents for the Alma
mater Conference, and so this topic of what is primary health care is what I've
spent. A lot of time, thinking about the
historical overview is important because, people have used different labels for
different parts of the Process. U.S.
clinicians just call it primary care because, they are dealing with the
indvidual focus, and the, first contact that patients, and, healthcare providers
have, is their focus. During the early days of this field, as
it developed and Than we have mentioned this later particularly as a result of
the work of Kark in South Africa. There was a common term used in public
health in the United States which is community-oriented primary care, COPC.
PC. This is the name that's been applied to a
lot of what's been done in the US and Israel because when Kark left of South
Africa because apartheid became too Difficult for them to cope with.
He moved to Israel and started it there, and other members of his team then moved
to the US. Carl was the leader who developed the
whole idea of primary health care as it was first applied in South Africa, Then
the Alma Ata Label was what we called the concept of Primary Healthcare.
Alma Ata conference we first defined it called Comprehensive Primary Healthcare
and then after 1984 there was a change and they called it Selective Primary
Health Care because they said if the donors will not willing to.
Wait in order to do the comprehensive process, they wanted to be very
selective, and that was a period of very great confrontation between the 2
perceptions. And then recently we've been.
Focused mainly on community based primary health care, which is the terminology
used now by the action group which meets each year at the American Public Health
Association annual conference, and they are very actively building on this
history in order to adapt it to the current situation around the world.
Seed-scale is the terminology that we use for a new approach to doing primary care
for the whole social development activity rather than just for health and here we
talk about integrated community based social development and this is
particularly sponsored by a NGO called future generations that I've been working
with for the past 10 or 15 years. Looking at the broad sweep of history,
there are ancient systems of healthcare that still persist, particularly in China
and India. There used to be a very important
tradition in Greece with Hippocrates and the leaders who then essentially
formulated the European Approaches to healthcare.All religions had a major
component of healthcare built into their religious practices at the time when We
didn't have the scientific understanding, and that was particularly in the hands of
different kinds of Shamans. I've always been interested in the most
community based primary healthcare, which was in Babylon.
Proposed them a public square there, if somebody who's sick, they put him in a
bed, and took him to the square and anybody who came by was supposed to come
by and give them advice. On what he could do to improve
healthcare, and that is something that we certainly don't do anymore.
It used to be very common. So the original exchanges in
international health has very amazing similarities between systems around the
world. There are a lot of countries.
That believe in hot and cold foods, which means that people are not, the foods are
not considered hot or cold either because of temperature or pepper, but they are
hot and cold because of what they do to the body They produce this kind of very
specific effect that people talk about. Then there are the spirits that were
considered so important in causing ill health and then the humors that the
Greeks talked about were very similar to what we find in the Ayurvedic system in
India and the miasmas were considered so important in Europe and then all the
healing practice that spread around the world.So,most of the early systems of
health care focused on prevention and on integrated services,rather than on what
we see now. And in the pre-scientific period, it was
this syncretism was the process of exchange.
Any new idea that came along that people thought worked would be shared.
There was a. Worldwide sharing.
This was all based on the most simplistic understanding of causes which changed off
course and Hippocraties was important not only because he was.
an important leader in Greece, but he was the one who started separating medicine
from public health because he recognized the geographic Patterns that certain
diseases had. In the Indian and Chinese systems
particularly, there were certain classics that were still used in the trading
programs that are done in the Ayurvedic system in India The Charaka, Susruta,
Vagbhata are basic texts which are still being used and then with independence the
Chopra commission in the new government in India was formed specifically to bring
back. The old Ayurvedic systems, and so they
produce legal recognition, but they've had a losing battle with the commercial
success of Western doctors and the pharmaceutical industry that has taken
over. And so there was a switch on to these
ancient herbs, the India National Institutes, were formed to go back to
study, wether there was anything [UNKNOWN] in the ancient herb, that would
lead to, better health and there are a few successes, such as the Rauwolfia
drugs for hypertension came out of Indian Himalayan herbs.
And so now we see piracy Around the world of commercial companies going out and
tapping into all of this accumulated knowledge and then taking the medicine as
a way from the countries in a way that means that the country does not get any
profit from it. And this results now, in the commercial
eradication of plants, when production becomes, profitable, for the drug
companies and they, lead to, the destruction of the ecosystems where these
plants are growing. And in China, again there's, similar
Pattern that has been very evident, and it goes back to what is called a Yellow
Emperor's classic. There's been a great effort particularly
in China to integrate the traditional systems with modern medicine.
The modern origins of primary healthcare go back to Virchow in Germany, who was a
great pathologist but he developed the general idea of social medicine then post
World War I. In England, there was a report, called
the Dawson Report, that led to, the Peckham health center and then, a network
of health centers in the U.S. then.
There were social Work and health centers.
But the first paradigm of the international development of what we now
call modern primary health care goes back to a place, Ding Xian.
Which is a district in China about 200 kilometers south of Beijing where there
was the first published demonstration of the concept that we're still learning How
to do and to get accepted in the modern health care.
The important thing about this Ding Xian process was that even though it started
in the late 1940's it became very important things of 1950's as [INAUDIBLE]
and the communist revolution took over China.
And this project became the basis for the barefoot doctor system, which then was
serving, mainly through the 1960's and 1970's, a quarter of the worlds
population, with the most equitable system, of healthcare that's yet Been
devised because in 1980s that collapsed with Dung Shao Ping and the economic
performance of the post-Mao period in, so that now China has as severe inequity.
As the United States, which is very sad to see.
The Barefoot Doctor system was designed specifically to have a person at
community level who was trained to provide healthcare.
And that came out of the Deng Xiao project then was picked up by Mao and the
communist government as the national program that proved very effective.
And so now we turn to the second and third generation projects, which, from
the late 1930s to the 1950s, people followed a [UNKNOWN] model, which had
been actually done and promoted by. by John B Grant from the Rockefeller
Foundation, and then C C Chen and Jimmy Yen from China.
Next generation project from that beginning was with Heydrich in Indonesia
Stampar, in Croatia, Eloesser in Chile and then in China, and other people who
took those ideas and then implemented projects.
That was a major historical contribution of the Rockafeller Foundation, who
developed Headers in about twelve or fifteen countries around the world, and
particularly important with these headers that we have established in Sri Lanka and
Kerala, which were carried on very successful is resulted, Of that start
back in the 1950's, and became the basis of formal health systems, that was
studied in the 1970's and 80's, where we were asking the question, how do these
Places developed the lowest cost type of health care, which proved so effective.
Then in the late 1950's, [INAUDIBLE]. South Africa started the Pholela, health
project, that became the first basis, for this kind of work in Africa.
Then in 1960's and 70's, we have the Narangwal project, that we'll be talking
about in this course, that was Fendall's work.
[INAUDIBLE], Geiger, brought the work that, Clark had done at Pohlela, to the
U.S.and it became the basis of the, OEO, under Johnson project system, that is
still present in the U.S. And then, the Aroles, in Jamkhed, well,
started a project. That we will also be talking about.Then
the nineteen seventy's,we had the water shed conference.The world conference on
primary health care [UNKNOWN] Let me just turn now to something that people usually
don't talk about too much which is the systems of traditional practitioner.
Which is true around the world. We shouldn't think, that there are
countries that didn't have healthcare, when we bring in modern healthcare.
Because, every country had some system for taking care of sick people, and
health patterns, that controleld behavior.
And so now we see a constant dillemma. In developing countries, of the
competition that result with traditional practicioners and modern practitioners
who then labelled them as quacks, and so We have many anecdotes of this
spontaneous syncretism that happens today.
When these quacks see medicines that are being sold in pharmacies, they use them.
And they move in to just adding them to their own practices.
So, we see this use of western drugs, which compared to ancient practices,
which often do work better, they just use them.
And so there were many studies in the 1950's and 60's and 70's about this
traditional practioners and particularly traditional birth attendants which led to
efforts to integrate them and absorb the main to the form of health system.
But things were never very successful, and they're still major ambiguities,
about what happens and why, in these efforts to integrate, and why so often,
they end up with a competition, and not cooperation.
So we have the question now, what is the place in community based primary
healthcare, of these traditional practices? Practitioners in the, poroused
and most, remote areas. And here we, now, in public health,
trying to, attract people to, work internationally and, one of the things
that we keep asking, how could we make, the routine Work that is so necessary in
areas of great need seem interesting. And one of my practices has been, to
always look as you get into And these are [UNKNOWN] situation where there is the of
traditional practice and modern effort, always look for the natural experiment.
So what you look for is, be looking at people, rather than just at the numbers
that we collect in our statistical studies.
And we really do miss the, good old days, of the infectious epidemics because, when
you had an epidemic, you had to pay attention.
To prevention, and you had to pay attention to causation, and then
prevention was built on the understanding of what the causes really were, and then
you could aggressively Introduced the inventions.
One of my old friends in Boston was Pat Rubinstein who was a chief Massachusetts
epidemiologist. And he had a lecture which he gave to
medical students which was based on question when do I get up out of my
chair? When do I need to do a personal investigation? Is it time for shoe
leather epidemiology, when you go out and see what's really going on.
And that's when you can really make a difference in terms of adapting whatever.
The standard methods are to the reality of the local situation, and so the
question we're always asking, what can I do to make a difference, and how? We're
going to be talking about these issues a little more, because in one of the
Subsequent lectures will go into the ratio of how can you actually prepare
doctors in medical education in developing countries,who will actually go
and work in the villages.