September 2008

Meet Our Featured Guest Columnist:
Dr. Carl Taylor

is professor emeritus in the department of international health at the Johns Hopkins Bloomberg School of Public Health. He was part of the team of global health experts that wrote the research documents for an historic meeting at Alma-Ata, in 1978. At the time, more than half of the world’s people did not have access to affordable, local health services and many were without the basic needs for survival. Delegates laid out a vision to improve daily life and bring health care to all.

Q: What does "health and human rights" mean to you?

A: Bringing health and human rights together expresses a sincere response to the deepest hopes of the billion people in greatest need around the world. The phrase should be more specific, Good Health Is A Fundamental Human Right.  Everyone has some kind of health but for the poor, health is usually also poor. But poverty in money is only part of the real life causes along with many other influences such as behavior and habits, which are often even more important. The Rich often also have poor health since their diet is rich with the wrong kinds of luxury and quick foods and they don't get enough exercise.  

For example there have been dramatic changes in ChinTraditional diets in rural areas have for centuries been well balanced with good vegetables and lots of hard work and the people generally have been quite healthy. Now as city people get richer the shift to Western diets is leading to serious problems with health, especially obesity of children and youth while in the villages many children still have severe malnutrition. Health in the future will depend on behavior change preserving good practices balanced by the Human Right to the essentials of good diet, living conditions and health care.

Q: How important was the meeting at Alma-Ata, and why?

A: It was one of the great privileges of my life to be part of the World Conference on Primary Health Care at Alma-Ata in Soviet Kazakhstan in September 1978. Dr. Halfdan Mahler, Director General of the World Health Organization was the visionary leader who planned the conference and persuaded the countries of the world that this was the highest priority for Global Health. The various UN Agencies were having World Conferences on topics such as Population Growth, Habitat (Living Conditions), Women's Rights, etc. Dr. Mahler articulated the main purpose at Alma-Ata to focus on the growing global inequity as rich countries had epidemics of the diseases of affluence, such as deaths caused by tobacco, while poor country epidemics were still the old infections and malnutrition. Dr. Mahler pointed out the tremendous progress in rich countries with complete health systems, where most of the money was spent on hospitals and specialized care.

Q: How/why did you get involved in global health issues?

A: I was Professor and Chair of the Department of International Health at the Johns Hopkins School of Public Health and became one of the consultants for WHO and UNICEF. A small team of us wrote the Alma-Ata background documents presenting the evidence on which conclusions were based. We recognized that poor countries would not be able to finance sophisticated, specialist care. It was agreed that they deserved the best level of care possible using available resources and focusing on simple and realistic scientific methods adapted to the needs of the poor.

We were able to draw on our recent research and WHO/UNICEF published two books of nine case studies that showed dramatic improvements, particularly in health of mothers and children. These changes in care could be made rapidly by building capacity among the people to solve their own health problems. The essential foundation for the new health model was to train community health workers who lived in the villages, mostly volunteers. They focused on simple methods in the community and home to care for the common health problems.  New breakthroughs for simplified scientifically validated interventions had just been published for the main causes of death: use of safe water and latrines; immunization for six childhood infections and for mothers to transmit immunity to her baby against tetanus which was the fourth cause of death in Indian villages; early diagnosis and care for babies from conditions such as diarrhea treated by Oral Rehydration, and pneumonia diagnosed by rapid breathing and treated by antibiotics (which were the number one and two causes of death around the world); and better nutrition care and breastfeeding.

Q: Describe some of the successes you have seen in your work.

A: An important model at Alma-Ata was the Chinese Barefoot Doctor program. Using simple traditional methods they had made tremendous health improvements in China under Mao. For over twenty years this was one of the most equitable systems ever devised. These barefoot doctors provided care in every village under the commune system of work points. But during the economic reforms in China in the 1980s the whole system collapsed because support through work points was eliminated under economic reforms for a market economy.  I was UNICEF Country Representative during those years and was amazed at the speed of the collapse of the model we had so admired at Alma-Ata.

However, the growing economic reforms brought a health system with inequities almost as great as in the U.S. In the poor Western half of China health conditions became much worse than the richer Eastern half. However, with UNICEF support we were then able to show that community based care could double child survival in the three hundred poorest counties. Now in 2008 a new national program for child health insurance is planned to show that China can again be a model of good care, especially for children and youth.

Q: What are some of the challenges?

A: The main challenge is that the Alma-Ata Community-based Primary Health Care model which was unanimously accepted by Ministers of Health around the world in 1978 has not been implemented systematically. Most leaders in health services have shown continuing skepticism about the notion that people can successfully participate in decisions about their own health care. There have been more failures than successes in 30 years of experience. Typically the experts blame the victims who are the poor who have not performed as the experts told them to. The most common negative finding documented over recent years is a lack of sustainability of what were called community projects but were imposed on the people with no sense of their own ownership. Many millions of dollars are still being thrown at specific diseases in what are called vertical projects of top-down design and practice. Eventually the outside money moves to other vertical causes. Dependency is then a chronic problem as the poor people wait for someone to come, give them health care and pay for the services that people have been trained to just accept.

I have been working recently from Johns Hopkins with a new model, SEED/SCALE, developed by a NGO (Non-governmental Organization) called Future Generations, which shows great promise in countries such as Tibet/China, Himalayas in India, Peru and Afghanistan. SEED is the planting of locally adapted community based projects of Self-help and Self-generated resources. SCALE is taking that demonstration to rapid extension which spreads exponentially since it grows from many nodes of development in Networks of SCALE Learning Centers. My son, Dan, and I have described some of these successes in a book, Just and Lasting Change: When Communities Own Their Futures, Johns Hopkins University Press, 2002.          

Q: How can young people make a difference?

A: Our experience is that it is the young and youth who get the point quickly of the idea that people can and want to have control of their own health care. They are the most spontaneous and imaginative of community activists who can make a difference in how health systems will evolve in decades to come.