A decade of progress : Alma-Ata and Riga / by Sir John Reid

ALMA-ATA AND RIGA A decade of progress Alma-Ata and Riga, the re-spective capitals of the Ka-zakh and Latvian Soviet So- cialist Republics, are separated by over 3,500 kilometres. One has as its backdrop the rugged magnifi- cence of snow-capped mountains, whilst the other is lapped by the waves and, in winter, by the ice floes of the Baltic sea. Yet these two cities share something unique. In 1978, delegations from 134 Member States of the World Health Organization, together with repre- sentatives of 67 organizations from the United Nations family, other agencies and non-governmental bodies, assembled at Alma-Ata, un- der the joint sponsorship of WHO and UNICEF, in. order to decide how primary health care could best be defined and developed as the key to achieving the goal of "Health for all" which had been adopted by the 1977 World Health Assembly. A decade later, in 1988, a techni- cal group met in Riga to assess pro- gress in that great project and to make recommendations for the pe- riod up to the beginning of the 21st century. For me, it was both a priv- ilege and a pleasure to be involved in both of these historic events, the first of which led to the Declaration of Alma-Ata, and the second to the Reaffirmation of Riga. The meetings at Alma-Ata and Riga, as well as being separated geographically, were also separated by the passage of a decade in the troubled history of our planet. East- West tension had, mercifully, di- minished but the overall propensity for human beings to kill each other had not; and the North-South gulf between the haves and the have- nots remained unbridged. The roles of wHo as one of the major stands of the conscience of humanity, and as a forum in which a global dialogue can still take place with a minimum of political posturing, thus remain as crucial as ever. 18 by Sir John Reid The conference at Alma-Ata had been preceded by a serious of na- tional, regional and other meetings with, as their common theme, the evolving approach to primary health care; and reports on their conclusions were available to dele- gates. The key document for discus- sion at Alma-Ata, however, was the joint report on primary health Sir Joh.nReid is Governor and T • Vic~.-Chairrnan ofthe ~oarq of Manag\')ment ..• ,of the" Lopdon School . of Hygiene •• and Tropical Mepicine~ . .A <;•f grmer Ch.ief. Medical . Officer. for Scotland, he headed the .. : . .UK. deleg~~ion, •·· to successive World Health As~ sembl.i.es Jron1' 1 l97~ . to 1976 .. He wa~Vi9e PQairm~p of WHO's · Exegutive .• E3oardtr9m 197~ ·t<:) ... 1£:)75, an · h · · ,1978 · · to 1979. care by Dr Halfdan Mahler, out- going Director-General of WHO, and Mr H.R. Labouisse, Executive Director of UNICEF. This, in only 133 paragraphs, set a comprehen- sive agenda for the definition and establishment of primary health care, including such vital issues as the inter-relationship between health and development, the full range of operational matters which must be covered if such care is to be translated from theory into prac- tice, and the preparation of nation- al strategies. The work of the Alma-Ata con- ference then proceeded in plenary session and in three committees, one dealing with primary health care and development, one with technical and operational aspects of primary health care, and one with national strategies and interna- tional support. Discussion was in- tense ; and the atmosphere was in some ways like that of the annual World Health Assembly, but with the advantages of being more fo- cused and substantially devoid of extraneous political matters. The culmination of the confer- ence was a series of 22 recommen- dations, addressed mainly to gov- ernments, but also to international organizations including, of course, WHO and UNICEF. The meeting closed with the solemn reading of what rapidly became the classical Decla- ration of Alma-Ata by Dr Marcella Davies, Chief Medical Officer of Si- erra Leone. As delegations and rep- resentatives boarded their planes at Alma-Ata to return to all corners of the world, we had a clear feeling that we had participated in a gath- ering of historic importance, and in one whose far-reaching conclusions demanded that they be translated from well-formulated words into equally well-founded actions. Much has happened since Alma- Ata, with the evolution of national, regional and global strategies for moving forward towards an accept- able level of Health for all, together with the gradual building up of monitoring processes. These last ac- tivities resulted in the publication, in 1987, of the Seventh Report on the World Health Situation, which took the form of the first global evaluation of the strategy for achieving Health for all; and it is a strikingly encouraging fact that no fewer than 88.6 per cent of WHO's Member States participated in the process, even if some were under- standably able to do so in greater detail than others. In contrast to the scale of the conference at Alma-Ata, the Riga meeting of 1988 was attended by only 22 invited participants drawn from all parts of the world and in- cluding parliamentarians and a range of health professionals. A strong WHO team led by Dr Mahler was also present, as were represen- tatives of UNICEF, UNDP and a non- W ORLD HEALTH, Aug./Sept. 1988 "The North-South gulf between the haves and the have-nots remains un- bridged. " The spectre of famine .. . Competition Photo by L. de Toledo (Switzerland) governmental organization. The objectives of the meeting included a review of progress towards Health for all since 1978, the identi- fication of likely impediments in the period up to the year 2000, and the suggestion of consequential steps which would require to be taken by countries and by WHO and other agencies. At Riga, the basic document for study was, "From Alma-Ata to the year 2000; Reflections at the mid- point on progress and prospects", prepared by Dr John Bryant, Pro- fessor and Chairman of the Depart- ment of Community Health Sci- ences at the Aga Khan University in Karachi, Pakistan. Dr Bryant was, incidentally and in common with several others present at Riga, a veteran of the Alma-Ata confer- ence. The proceedings were fol- lowed with close interest by ob- servers from all 15 Republics of the USSR, and not least by our hosts of 10 years previously in Kazakhstan. In contrast to the conference in Alma-Ata, with all the high drama of an international event, the Riga meeting was small in scale ; and it succeeded in being simultaneous- ly intense in its work and yet re- laxed in its atmosphere. The 1978 event was concerned with defining and agreeing major policies in a way which had never before been so comprehensively attempt- ed, whereas its successor of a de- cade later was occupied with criti- cal evaluation and with the need for consequential adjustments in policies within the framework for the development of primary health care which had been agreed by the Member States of WHO. It was not the objective of the Riga exercise simply to rehearse the high ideals and endeavours which had their origin at Alma- Ata ; instead, it was a concentrated attempt to ensure that what had been decided ten years previously continued to be valid, and that areas which called for intensified efforts in the struggle for Health for all were identified. The meeting came to the conclusion that the ob- jective of Health for all should in- deed remain the goal of all coun- 19 A decade of progress tries not only up to, but beyond, the year 2000 ; and that each should continue to identify its own priorities in relation to health prob- lems and to underserved and vul- nerable groups of the population. There must be no slackening of social and political action in the fos- tering of health, and this must be more effectively harnessed with the endeavours of other social and economic sectors, both governmen- tal and unofficial. The role of people must become increasingly dominant in terms of empowering them to take decisions in relation to their own health ; and there is need for much greater efforts to develop health manpower and leadership for Health for all. Particular em- phasis was laid on the need to strengthen district health systems based on primary health care ; and there was continuing need to en- sure the further advancement and rational use of science and appro- priate technology to help the devel- oping world. The meeting also identified a series of areas which called for particular attention, not least the unacceptably high loss of life amongst mothers and young children in all too many countries, but especially amongst the least developed ones. A report on what took place at .. . and a picture of health. " The meet- ing in Riga confirmed that great pro- gress had indeed been achieved. " Photo WHO/D. Taylor Riga has been published and, as was the case with Alma-Ata, will give rise to widespread discussion among all who seek to promote health through the key medium of primary health care. The Reaffir- mation of Riga clearly proclaims that the conclusions reached at Alma-Ata were on the right lines, but at the same time reminds people and their governments that much still remains to be done. As a Scot, I can advance a mod- est racial claim to the power of prophecy. However, that was not required when, in my speech as Chairman of the Executive Board at the opening plenary session at Alma-Ata, I said that, when we came to look back from a historical perspective, the name of that place, as well as being that of a beautiful and hospitable city, would become synonymous with a major step to- wards even more rapidly making primary health care something which is real and relevant to the needs of the entire human race. Prophecy was not necessary, as the tide had already begun to move in that direction, and the mood of those gathered together at Alma- Ata was, from the outset, clearly destined to transform it into a flood-tide. The meeting held 10 years later, in Riga, confirmed that great progress had indeed been achieved, but that the time was ripe for national and international re- dedication to a great and humane endeavour. Whilst many people, both at the rostrum and behind the scenes con- tributed to the success of the meet- ings at Alma-Ata and at Riga, one charismatic individual played the dominant role at both, in the form of Dr Halfdan Mahler, Director- General of WHO from 1973 to 1988. He combines a rare group of char- acteristics, being at one and the same time a visionary, a natural leader, an intensely caring human being, a supreme health strategist, and a practical physician whose clinical roots were in the fight against tuberculosis. Under Dr Mahler's leadership, the World Health Organization has been transformed in philosophy from being a benignly paternalistic international agency to a true health cooperative of 166 nations; whilst its practical utility has been fully demonstrated in activities ranging from the eradication of smallpox to the global fight against AIDS. Dr Mahler's unique and shining qualities have led to the World Health Organization's be- coming the most highly regarding agency in the United Nations fam- ily; and the core theme of Health for all, firmly based on primary health care, has been developed and steadily translated into reality under his leadership. There can be no doubt that, as successive histories of the Organi- zation and its achievements come to be written, the period of Halfdan Mahler's Director-Generalship will always be recorded as having been a golden age. •