Perspectives in Health Magazine |
Alma-Ata Revisited (continued) A Soviet proposal No one thought about an international conference on the subject, however, during the 28th assembly; the prevailing wisdom was that new experiences were needed in this area. Then in January 1976, a day before the meeting of WHO's Executive Board (prior to the 29th World Health Assembly in May of that year), Dimitri Venediktov, the powerful Soviet vice-minister for international affairs in the Ministry of Health, came to see me at my home in Geneva. He proposed holding a major international conference on primary health care and offered $2 million as an extraordinary contribution by the Soviet Union. He explained to me that the leading socialist power could not allow China a victory within the Third World. His proposal came as a great surprise, and my argument that such a conference would be premature-and that it should not take place in Moscow-did not seem to convince him. Venediktov presented his proposal at the start of the WHO Executive Board meeting and, under considerable pressure, conceded that such a conference should take place in a developing country rather than in the Soviet capital. The idea was formally accepted four months later at the World Health Assembly, and the conference was scheduled for 1978. I was designated by the director-general as general coordinator in charge of the technical, logistical and political aspects. The task would take me 29 months and several trips to the Soviet Union and other countries.
Once Moscow was ruled out, the search was on for another location in the Third World to host the conference. It was a difficult task, given the economic and logistical implications of such an undertaking. There was an additional cost of slightly more than $1 million over the original $2 million offered by the Soviets. San José, Costa Rica, was discarded when U.S. support could not be secured. Cairo was also rejected when the oil-producing countries from the region failed to provide the required support. I traveled to Iran to see if Teheran might host the event, but I only managed to interest the Shah's sister, Princess Ashraf Pahlavi (she later became one of six vice-presidents of the conference). Finally, there was no other practical solution than to select a city in the Soviet Union other than Moscow. Venediktov and I discussed possible venues and traveled together to Baku, Tajikistan and Alma-Ata. The decision had to be made by the Soviet government, and I only made a detailed chart of the minimum physical and logistical requirements. But once again my friend Venediktov taught me a lesson in political management. At all three sites he introduced me as the person who would make the final decision. The choice of Alma-Ata was due to two fundamental considerations: the dynamism and leadership of Kazakhstan's minister of health, and the feasibility of having the required physical infrastructure ready on short notice. Alma-Ata, which means "father of the apples," was in the republic where the Soviet Union had its Cold War space programs. It was also next to China. The work undertaken by the government and the Ministry of Health of Kazakhstan was truly extraordinary. In the space of a year, they built, among other things, a hotel with 1,000 beds. The magnificent Lenin Convention Center, with its auditorium for 3,000 people, had a simultaneous interpretation system and earphones at each seat. However, the communications system was one-way- that is, from the podium to the delegates and not vice versa-so another system had to be brought in from Italy. Other problems were solved in the course of several trips. To facilitate immigration and customs procedures in Moscow and Alma-Ata, we flew in the entire staff of the WHO secretariat; it took two airplanes. But in the end, everything proceeded without delay. U.S. Senator Edward Kennedy, who arrived at the last minute and not as an official member of the U.S. delegation, was well received. His presence demonstrated the political importance the conference had achieved. Working documents were prepared one year ahead of the conference. Following consultations with governments and other organizations, these became official documents for the conference's review and approval. The Declaration and Recommendations went through 18 drafts revised in meetings in the six WHO regions, in the Special Meeting of Ministers of Health of the Americas in 1977 and in meetings of special country groupings and certain individual countries as well. The conference was prepared as an open, decentralized, democratic and participatory process, though this was never formally declared. The draft that was officially presented contained a few changes that, in hindsight, contributed to the later distortion of the original concepts. Many delegations and individual delegates fought to include details that had more to do with medical specialties than with health. It was important that the conference was cohosted and jointly organized with UNICEF. This was difficult at the beginning, but the work done by two key UNICEF representatives, Richard Hayward and Newton Bowles, was instrumental in winning over Henry R. Labouisse, then executive director, and securing the active participation of the agency. I still consider it a privilege to have worked so closely with UNICEF and to have continued that close collaboration until my departure from WHO. It is regrettable that afterward the impatience of some international agencies, both U.N. and private, and their emphasis on achieving tangible results instead of promoting change-something that is always difficult-led to major distortions of the original concept of primary health care. So-called "selective primary health care" and packages of "low-cost interventions," such as GOBI and GOBI-FFF (growth monitoring, oral rehydration, breastfeeding, immunization; female education, family spacing, food supplements), as well as other variations contradicted and distorted the spirit and concepts of Alma-Ata. A new era In today's globalized, unipolar world, where national sovereignty is increasingly threatened, one of the few ways in which countries can still control their own destiny is through the development of genuine, decentralized and participatory democracies. Nowadays it is essential to transfer, or rather, to return political power for social decision-making to its point of origin, that is, the citizenry. Integral health care for all and by all-perhaps the best way to phrase Alma-Ata's call for genuine primary health care-is a necessity not only for health but also for the future of countries that aspire to remain sovereign nation states in an increasingly unjust world. There have been major global changes and many important new experiences in the world during the 25 years since the first International Conference on Primary Health Care. Perhaps it is time now to convene an Alma-Ata II, to set forth again, without distortions, the original concepts that led to that conference in 1978. David A.Tejada de Rivero was deputy director-general of the World Health Organization from 1974 to 1985 and twice served as minister of health of Peru.
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