Welcome everyone to our first lecture on primary health care as a means of
reaching health for all. The title of this lecture is called
Primary Health Care in Developing Countries: Origins, Principles and
Evolution. This lecture was originally recorded for
a course I teach here at the Johns Hopkins School of Health called
Introduction to International Health. And so, there will be several points in
the lecture, particularly at the beginning where it will be obvious that
this was recorded initially for another purpose.
But the first lecture that you'll be hearing today is a portion of a larger
lecture that this recording is taken from.
And then next week we will be listening to another portion of this lecture for
the first half of next week's lecture. And then the second half of that will be
a recording that Carl Taylor made before his death about the origins of primary
health care. ·I am very pleased to be sharing all this
information with you. It's of deep value to me personally and
so the oppertunity to share these important historical expirences and ideas
and principals are a great priviledgefor me, so welcome.
As you know I'm relatively new to Johns Hopkins.
I've been on the faculty since 2009 and my own career evolution started out first
as an MPH student here in the early 1970s and then I trained in general surgery and
during my residency training I had the opportunity to visit the Hospital Albert
Schweitzer in Haiti. I worked in Bolivia in the early 1980s
starting a community health program and I was doing surgery as well at that time.
I spent ten years living in the mountains of North Carolina practicing surgery and
also providing leadership to a small NGO that I started called Cure America,
originally Andino Health Care and I'll be mentioning a little bit about that.
And then in the middle 1990's, I had the great privilege, of moving to Bangledesh
and working with Johns Hopkins on a project there at the International Center
for Diarheal Disease Research, and later with the basics project, concerned with
child survival in Bangledesh. And so I'll be referring to, some of my
experiences there in Bangledesh, and then following that I have the great honor of
serving as the director of the hospital Albert Schweitzer in Haiti, which I had
first visited quite a few years earlier, and I'll be speaking a little bit about
that. Starting in 2000 I spent a number of
years working with Future Generations which is an NGO that Carl Taylor started
along with his son, and I'll be mentioning some of that as well.
As we go through this, I'll be talking off and on about Carl Taylor, who founded
our Department of International Health here in the early 1960's and was a
passionate proponent of primary health care and in fact global leader of primary
health care, so we'll get into that in just a minute.
But it's a recurring theme through all of this.
Carl always felt that John B. Grant was the father of primary health
care. John Grant was a very distinguished
physician who worked with the Rockerfeller Foundation in a number of
countries, but his most important contribution was his work in China back
in the 1930s. And at that time he worked with some of
the very well known chinese people concerned with improving the welfare of
rural China, most notably Jinny Ann and CC Chin and through that project gained a
lot of experience that was very influential on the development of primary
health care. He wrote this book, which Carl always
referred to as the bible of primary health care, published by the Johns
Hopkin press in 1963 called Health Care for the Community.
But, in that book he really repeatedly talks about how the community can and
should be linked to health systems and how health is an integral part of
development and how training and research need to be built into all of these
activities in order to make real solid progress.
This general philosophical approach is reflected in this statement from John
Grant's book in which he talks about the need to demonstrate feasibility and worth
in projects and programs and to make use of technical methods which are
scientifically efficient and economically practical.
And the need to integrate programs horizontally rather than working in
narrow single activities this was written back in 1934 and the themes that he
touches on here continue to resonate as being important once for us to consider.
The project that John Grant helped Jimmy Yen and CC Chen develop was called Ding
Shen. It was 100 miles from Beijing.
At that time China was among the poorest countries in the world and in the rural
parts of China certainly conditions were among the very worst in the world.
And resources were extremely scarce, and health facilities, health professionals
were extremely scarce as well. And so in the midst of that context,
these three people developed some ideas that seemed kind of simple but still they
were very profound and had an enormous influence.
The first thing they did was they conducted surveys to identify what the
health problems really were, and then they trained local people,
non-health care professional people with no formal training or formal background
in health to begin to be engaged in important and priority health care
activities they got them engaged in recording vital events, vaccination
against small pox, administrating simple treatments, giving basic health
education, and maintaining wells, and these farmers, Farmer Scholars, as they
called them, became the forerunner of the Barefoot Doctor program, which later
became so famous, but that experience was also an important model for what later
became China's rural transformation and development.
But, this is all, explained in some detail in this wonderful book that Carl
Taylor, and his son Daniel, wrote called Just and Lasting Change, which I'll, get
to in just a minute. Carl Taylor's mentor, when he was a
student at Harvard, was a very, outstanding man, named John Gordon, who
actually worked in China with John Grant, so the personal connections of these
people and the ideas that they promoted and built upon, one leading to another
are interesting part of the primary health care story.
John Gordon, in his own work prior to that time had been involved in some work
in Romania, with the Rockafeller Foundation.
And he had onhis own developed the concept of routine systematic home
visitation as a way of providing surveilance data, and he was the first
person to record an epidemic from the very first case to the very last case.
This was an epidemic of rheumatic fever that he was always set up to capture and
through that experience as well as others he became aware that home visitation had
some real power to it from public health standpoint and I'll be referring to some
of this as we move along, but when Carl Taylor studied at Harvard Medical School,
and then later at the School of Public Health, he took classes in Epidemiology
from John Gordon and John Gordon taught a course on project development and he
served as Carl's mentor in the development of some very important ideas
that we'll be referring to. Also, you see that John Gordon was the
mentor of John Wyon, who was a friend of Carl's in India back in the '50's.
And John, as well, fits into this story in a number of different ways.
I'll get to that in a minute. Two of the towering figures in primary
health care are Halfdan Mahler and James Grant.
Halfdan Mahler is still living, James Grant died several years ago now.
But both were extremely dynamic and charismatic people.
James Grant was John Grant's son interestingly enough and he had grown up
in China and had quite an international experience prior to growing up and spoke
fluent Chinese and so forth and so. had quite a background for this role.
He was not a physician, but had worked in development programs, and had quite a
senior career in various development activities before becoming the executive
director of UNICEF. Halfdan Mahler had been a medical
missionary in India working in tuberculosis.
He is Danish and he was a friend of Carl Taylor's back in those early days in
India, but both of these people had long tenures at their respective organizations
and I think both are considered to be the most outstanding directors of these
organizations that they've ever had and this was an important.
Part of the evolution of primary health care that we'll get into in a minute.
Let me just mention a few words about Carl and his unusual background as well
as his enormous contributions. Here you see him as a adolescent I
presume, in India when he was growing up. And on the right you See him about two
years before he died when he had received an honorary doctorate from Johns Hopkins
University. His career in international health
spanned from age seven to age 93. So I think that math says that that's
about 86 years; extraordinary career.
He has had these accolades from very high powered people John Rohde, who was James
Grant's special assistant for 15 years considers him to be the acknowledged
leader of primary care over the second half of the 20th century.
And Hafdan Mahler was quoted in the New York Times after Carl Taylor died as
saying, that he's the greatest public health expert I have come across.
So, he's somebody that Johns Hopkins takes great pride in claiming.
Although of course he spent a large part of his life in other places before coming
to Hopkins. But still he started the Department of
International Health here and many people consider that he is the founder of the
whole field of international health, not to mention primary health care.
So his contributions are enormous. But here we want to focus on his old work
in primary health care. In this slide you see Karl Taylor's
mother and father. They were both medical doctors and they
were missionaries in Northern India in the Punjab and they spend most of their
time travelling from village to village. Treating people and their illnesses.
Here on the left you see Carl's father John treating the men, and his mother
Elizabeth treating the women, and they would spend their days engaged in this
kind of work. They had had the opportunity to work in a
hospital when they first went out there, but they later decided that they needed
to get out to the village where the people were, and to really understand and
respond to the problems on the ground. And this has importance and implications
in Carl's development as we'll see in a minute.
Here you see the kind of paripatetic life that they would lead.
they would go around in these ox carts with their things and go from village to
village. Here you see, in the bottom left, you see
Carl as a young child with his brother. And there pet anteater, and here in the
next slide you see Carl with the rest of his family and native Indian garb, so
it's a classic missionary family that's going native, you might say.
But they were very much ingrained in the local life there.
Then after Carl finished medical school, he went back to the same areas as a
medical missionary with the Presbyterian Church and soon after his arrival back,
their Indian independence came and there was partition between India and Pakistan
and there were massive riots and enormous blood shed and enormous loss of life and
he got engaged in responding to that and got his career started in a very dramatic
fashion. But, several years later, he got involved
in, developing, some interesting projects, in northern India, in the
Punjab where he had grown up. He worked with the Ludhiana Medical
College, and they started some projects to train local doctors to work in rural
areas, but another important project they got
involved with was something called the Khana study.
And here, you see Carl Taylor in shorts looking towards us and standing.
Next to him, to our left is a tall man named John Wyon, who had also gone out to
India as a medical missionary and became friends with Carl and they had a similar
interest in community health and what was going on in the villages.
I'll get back to that in just a second. So here you see the location of Narangwal
near Ludhiana, where the Narangwal project was and it's near where the
Khanna project was. The Narangwal Project was Carl's major
activity during his early years, and he had started on that before he came to
Hopkins as chair of the department. And for the first 10 years or so that he
was at Hopkins, it was the dominant activity in the department of
international health. But it was a pioneering primary health
care project that had quite a bit of community based activities that took
place outside the facilities, involving community health workers and home
visitations and so forth as you can see in these slides. But another interesting
part of this is that it was a very high powered research project with various
experimental cells. in which villages were assigned to
different kinds of groups for different kinds of activities.
And they had a very high level engagement of the Ministry of Health in these
activities. And once a year the project would bring
in the Minister of Health and other high level officials from Delhi to review the
findings of the nearing wall project and discuss their implications for health
care services more broadly in India. And here in this next slide you see Carl,
the very dashing man there with the tie on having a reception for these officials
at his home in the village in Narangwal. There are lots of interesting things
about the Narangwal project, that I don't have time to tell you about.
A summary of the project is in two volumes published by the World Bank here
back in the early 80's, but one of the interesting aspects of it is that the
staff lived in the village, mixed and mingled among all the other households
there. It wasn't like a separate compound, and
so this whole project was integrated into the life of the village and it had a very
important impact on the way the project moved forward.
There was a very strong participation of the community in the research project and
discussion of the findings with the community as well as higher level
officials too. But this project was an important
foundation for the 1978 Alma-Ata Conference.
In addition to the Narowal project, however, there was a growing recognition
that the international health work, up until that time, was becoming misguided.
And the reason I say that is because Christian medical missions were very
hospital-focused and people were realizing that these hospitals themselves
weren't really responding to the major health needs of the people.
There was an organization called the Christian Medical Commission that was
formed that had its office in Geneva. And they did a study in which they went
around the world and they looked at the health of the people who lived close to a
mission hospital, and they compared it to health of people who lived further away
from the hospital, and they concluded that there was no difference in the
health of people who lived closer to a hospital than people who lived further
away. And so that caused some serious thinking
about what was being accomplished by these ,, very prestigious hospitals that
focused on curative care mostly for adults.
That whole experience of the Christian Medical Commission had an important
influence, as I'll mention in a minute, on the ,, evolution of thinking at WHO.
In addition to the work of the Christian Medical Commission, the World Health
Organization sponsored the publication of a book called Health by the People, and
it was a very clear. from that book and the examples of
community health care from various places around the world that a whole new
approach was needed. And, that book certainly pointed out the
fact that the medical model of curative curve was not going to really be the
answer to the health needs of the population and much of this was hospital
focused. So, with that kind of background and Carl
Taylor's ,, close relationship to Halfdan Mahler, that went way back to their time
in India. Halfdan Mahler asked Carl Taylor to be
his special envoy and he played a key role in the development of what became
the international conference on primary health care in 1978 held at Alma-Ata at
that time it was USSR now in Kazakhstan. And Carl told me that he was going back
and forth to Geneva like a yo-yo, but he spent a enormous amount of time on that.
So, one of the interesting things that happened is that the people working with
the Christian Medical Commission in Geneva started talking to the high level
people at WHO, and Halfdan Mahler having come from a Christian Medical Mission's
background he knew these people and he saw the value of what they were doing and
so that relationship lead to quite a strong influence that WHO is described in
this article in the American Journal of Public Health in 2004.
Here you see the contents of this book, called Health by the People, which was
published in 1975, which was an important foundation for the international
conference on primary healthcare, and you see the discussion of the barefoot doctor
concept in China is the first chapter in this book.
But perhaps the most important chapter in this book was the one written by Maybelle
and Roger Rollies you see on page 7, describing the John Kit project.
The Rollies were students of Curl Taylor's and went to this very deprived
area of central India and started a project that within four or five years
had become world famous. And we'll get into that a little bit
more. But, so much of what happened at
Alma-Ata, I think was strongly influenced by what the Rollies did.
Here you see a photograph of the meeting itself, very much a Soviet-style type of
[LAUGH], type of setting obviously. The International Conference on Primary
Health Care that was held at Alma-Ata in September of 1978 was.
The most important global health conference that had been held in the
world up until that time. It was attended by leading health figures
from all over the world. And they focused on this very important
idea of what primary health care is and what it should be, what it might be.
And the outcome of this conference which is so important for our course, and so
important historically is the declaration that was unanimously approved by
everyone. We refer to this as the Declaration of
Alma-Ata. The Declaration is only two pages long,
and it's available on the internet, and you have it in your readings.
But what makes it special in many different ways is, first of all how well
written it is and how incredibly concise, but still profound the ideas of primary
healthcare are that can be seen in this document and we're going to be talking in
the next lecture, next week on what exactly is in this and you'll be reading
it yourself as part of the readings for the course.
But, just to give you a few ideas about why this is so important is that, first
of all, the concepts of primary health care that are described in the
declaration are very different from the idea of primary medical care in the
developed worlds, so for much of the world and particularly for scientific
experts and so forth, the notions here were very different from traditional
medical notions. And as I have said and will continue to
say, it very much focuses on what might be considered his first principles.
The very basic conditions that are needed within society to achieve health, whether
they're medical care treatment, or other so called social determents of health.
And as a result, it was not received very favorably by the more traditional medical
scientific establishment, and many considered it to be a radical attack on
the medical establishment, as well. But in fact, if you read and think about
what's in the declaration, I don't think that's true, but because it incorporated
new ideas that went far beyond simply the practice of, medicine by doctors, it
wasn't warmly received by everyone. Once it became known and discussed, and was
widely publicized following the international conference on primary
health care. When the Lancet published its series on
Alma-Ata in 2008 which was celebrating the 30 years following the conference,
Margaret Chan who is the Director General of the World Health Organization she made
this statement in an editorial that preceded the document which I think, does
a great job of focusing in on some of the key values that are embedded in the
Decoration of Alma-Ata, she said that it honors' the resilience and ingenuity of
the human spirit, and made space for solutions created by communities, owned
by them and sustained by them.' And so obviously, you can see just from
this that this approach to primary healthcare goes far beyond the
traditional medical model. I wanted to share with you, this
statement that came from Mabel and Roger Arole, in their book called Jam Ked,
which is one of the great classics of global health and primary health care.
And so, if you've never heard of it And, really want to get into this whole idea
of primary healthcare, in a deeper way, I strongly urge you, to obtain this book by
the Arole's called Jam Ked: A Comprehensive Primary Healthcare Program.
This sentence that you see on your screen here, again gives the sense of What, the
declaration of Alma-Ata is trying to get at.
Again, it promotes this idea, of working with local people.
Using, the capabilities that local people have, to engage with them, and enable
them to take responsibility for, and to take action to improve their health.
Again, very different approach, from the traditional medical model of curative
care provided by. highly trained physicians.
And so even though this statement is not actually in the declaration of Alma-Ata.
I think it gives a good sense of the deeper meaning of the declaration of
Alma-Ata. He goes on to say that and again, this
reflects the challenge to the medical model, he talks about the need to
demystify medicine, and to share knowledge freely with people, so that
they can attain and maintain good health. Hierarchical latitudes which
unfortunately are a dominant part of the medical model less so now but, certainly
a part of the history of medicine. Arctic latitudes have to be replaced by
team spirit and equality. The realization that knowledge not only
gives power but the cheering knowledge also increases self estimate is important
for the development of the team spirit. So, these philosophical elements are very
much embedded in the whole notion of Alma-Ata.
Unfortunately after the international conference on primary healthcare in 1978
and the enormous enthusiasm that was created, the whole movement underwent a
rapid decline. It's a very important part of the history
of global health to look at this and to think about it and exactly why these
things took place is also a fascinating question which people like to think
about, and I'm not sure the final answer has been written on that.
But for many people the whole notion of health for all, by the year 2000 which
the declaration of Alma-Ata called for was too broad and idealistic with an
unrealistic timetable. And at that same time as well the
importance of immunizations was being recognized and the low coverage of
immunization services in developing countries was becoming a problem in the
early 80s the coverage of immunizations in most poor countries was only 5-10%.
And so people, expert authorities like D.A.
Henderson, the former dean here, who was the leader of the small pox eradication
program at WHO began to push for an expanded program on immunization, EPI.
And also, at that time as well, world rehydration solution had been developed
as a very simple way to treat dehydration caused by diahrea, and so these twin
engines became very much the favored approach of Global health experts who
weren't in the same philosophical tradition of Alma-Ata, and they began
promoting this, and this became the beginning of what we call today the
selective primary health care approach. Vertical programs which have many
different characteristics from what was envisioned at Alma-Ata But, this later
emerged into, what was back in the eighties called as GOBI-FFF (growth
monitoring, oral rehydration, breastfeeding, immunizations, food
supplementation, female literacy and family planning) it was a sort of the
extention of a very near but still highly selective vertical approach. There were
lots of reasons why the selective approach became so much more powerful
than the Alma-Ata approach. Julia Walsh and Kenneth Warren, wrote
this very famous article in the New England Journal of Medicine in 1979.
Arguing for the cost-effectiveness of the selective approach to poverty health
care, and they made it very clear in their article that they saw this, not the
long term answer, but as a short term interim strategy for disease control.
And I think we're finally beginning to move out of this interim strategy and
towards a more comprehensive approach, but there's still a lot of debate about
these two approaches. And I'll get into this a little bit
further. We come back here to James Grant who
became the global proponent for the selective approach interestingly enough
in UNICEF with its resources and prestige was the dynamic force that that led to
the expansion of programs, particularly for oil rehydration therapy and for
immunizations. And James Grant was very famous for
traveling all around the world, meeting with heads of state.
And he would always pull out his oil rehydration salts packet and promote ORT
immunizations. Jon Rohde was his right hand man.
A compatent Harvard trained pediatritian, who saw the power of the selective
approach and they worked hand in hand on this, but Carl Taylor liked to remind
James Grant that his own father, John Grant, would not approve of what he was
doing because his father had a much more holistic approach, as that initial
statement indicated, that I talked about at the start of the lecture.
Other reasons for the rapid loss of momentum of health for all movement is
many people call the Alma-Ata concepts was the weak leadership at WHO globally
and also weak leadership at the country level in WHO and the medical orientation
of what many people refer to as the world disease organization rather than the
World Health Organization. But there was also a lack of strong
scientific evidence of the progress that could be achieved with the broader
approaches. And there was strong scientific
achievements that could be shown for oral rehydration therapy and immunizations.
So the scientific part of this was an issue and then there were the politics
that fed in this as well and many people considered Health For All to be a part of
the leftist, socialist, communist agenda, so that didn't help obtaining support for
it from the West and particularly the United States.
And so we have this ongoing tension that's still with us today after three
decades, more than three decades between the approach of what many people refer to
as a more horizontal approach, Integrated approach, grass roots approach, that
works with the felt needs of people and provides a broader scope of services, as
opposed to a highly selective top down Externally funded approach that's,
focused on, highly targeted, but still, epidemiologically important conditions
and diseases, but tied in with these two approaches are also some themes that
permeate global health more broadly, but particularly in the primary health care
as well and that is the reality that health problems are, as in particularly
in the very poor countries of our world today, are still very much a product of
the social and economic conditions of people and so creating a longer term
sustained improved response to health conditions, requires addressing the
social economic in terms of health, and that requires a political response in
order to make a real difference in the health in the longer term.
But at the same time we recognize that very dramatic things can be done with
inexpensive technical or biomedical interventions, such as the administration
of vitamin A, is a pill that you only need to take every 6 months, and that
reduces the mortality rates of children by 1/3.
So how can we not be engaged, as public health professionals in promoting these
simple low cost interventions as well? And so this deilemma continues with us as
I said the major funding programs today are very much disease focused.
The Global Fund to fight AIDS, tuberculosis, malaria, PEPFAR, the
President's Emergency Program for AIDS Relief, the President's Malaria
Initiative are all reflections of this top down vertical approach that are
extensions of Gobi and the earlier highly selective approaches.
But at the same time, the inability of these very narrow approaches to build up
health systems and to build sustainable integrated programs is also becoming
recognized as we're entering a new phase in which there's a broad agreement that
we need to be putting more emphasis on horizontal integrated systems approaches,
and also the need to engage communities and build them in as partners in this
process as well. So some people like to say that we have
all become diagonalists now. Jaime Sepulveda, a high level researcher
and policy advocate from Mexico. who more recently has been working with
the Gates Foundation, made the statement very powerfully, in
one of his lancid articles about, we need to have both people recognize that of
course the vertical approach is valuable, but we also need the horizontal approach
and they shouldn't be seen as competitors, but as complimentary.
Unfortunately, over this history after Alma-Ata, the vertical approach was so
dominant that the horizontal approach was sort of left behind, so we're now in a
faze of building up the horizontal approach.
The world health report in 2008 was focused on primary health care and they
mentioned some important issues that have detracted away from primary health care
one is what the call hospital centrism, so this early idea of a that I mentioned
with the Christian medical commission of needing to get away from hospitals.
Or, I should restate that. It's not the need to get away from
hospitals, but it's the need to get away from having hospitals as the center of
health program activities and by the center I mean where most of the money is
going among other things. That's been a major detractor for
developing primary healthcare services because the political pressure and the
people making decisions about funds have given priority to hospital services and
the high technology that goes along with them, and in addition to the
hospital-centrism, this report focused on the problems of commercialization and
fragmentation as being detractors towards the full development of primary health
care as we know it, and as a result of these forces that lead away from
permanent health care. We have problems today with health
equity, lack of access to care, and very unhealthy communities.
John Grant referred to public health, in this quotation that you see above here,
but it's got a strong relationship to primary healthcare.
Public' health is the science and art of social utilization of scientific
knowledge for medical protection by maintaining health, preventing disease,
and curing disease through organized community efforts.'
So it's those organized community efforts that are such a fundamental part of
primary health care which again focus on the non medical model of primary health
care and in this vein I wanted to mention some concepts that I learned from John
Wyon, who I have the privilege of working with for a long time in my early career.
John always referred to three kinds of public health: disease-oriented public
health, service-oriented public health, and community-oriented public health.
And this is where primary health care and public health become linked, at least in
my mind. We know that disease oriented public
health is focused on reducing the effective, a disease, and a population.
Services-oriented health works to get basic services out to a population which
I guess is a part of primary health care. Perhaps.
As long as those services are not hospital services.
But community oriented public health is focused on a practitioner of public
health working with a community or a set of communities to help that community
improve itself. And unfortunately, community oriented
public health and the primary health care notion that's linked into it is very
under-developed in academic public health, and it's very under-developed and
global health more broadly. John always used to like to say that
these three types of public health are like the three legs of a three-legged
stool, and they each complement each other; with one of the legs being weak,
the platform of the stool is weak as well, no matter how strong the other legs
might be. So, I've been going in some detail and
all of its history and some of the issues involved in the development of primary
health care. Lets take a brake and when we come back
we'll continue this discussion, but bring it into a more current context.