(Photos shared with us by and used with permission of Mike Toole)
Community health worker training during the Refugee Health Unit (early 1980s).
Monkeypox and primary health care are hot topics in the global health news this week. The World Health Organization (WHO) and Multilateral Development Banks just kicked-off the new Health Impact Investment Platform, designed to pump $1.5 billion into “the critical need for coordinated efforts to strengthen primary healthcare (PHC) in vulnerable and underserved communities to build resilience against pandemic threats like mpox and the climate crisis”.
Here at the Developing Humanitarian Medicine project, we’ve been thinking about the meaning(s) of PHC over time. We’re currently undertaking a case study of the Refugee Health Unit in Somalia, which was run by the Somali Ministry of Health in the early to mid-1980s and has been described as one of the largest PHC projects ever embarked upon. Surprisingly little has been written about the Refugee Health Unit – it doesn’t appear in Randall Packard’s seminal A History of Global Health or any of the articles that we’ve found on the origins and early years of PHC (like Marcos Cueto’s article) or the shift to “selective primary health care” (essentially bundles of cost-effective health interventions). We have, therefore, been tempted to think of the Refugee Health Unit as a case study of historical memory: a provocation to think about why some major programmes make it (or not) into grand narratives of global health and humanitarian medicine.
Yet, when interviewing national staff and expatriate advisors to the Refugee Health Unit, we’ve realised that many of them see their time with the unit as having a major impact on their subsequent careers and conceptualisations of healthcare delivery. Some non-governmental organisation (NGO) staff have also mentioned to us that they consider PHC approaches to be alive and well in current humanitarian settings. Might this apparent discrepancy about the role of PHC in humanitarian medical settings come down to definitions? Anthropologist Katerini Storeng has done fascinating work tracing the definitions of “health system strengthening” at global health institutions. In her 2014 article, Storeng shows how powerful actors like the Gates Foundation and Gavi (the Vaccine Alliance) can hijack terms like health system strengthening, effectively divorcing these concepts from their original contexts and using them to advance their own agendas.
Inspired by Storeng and putting our historian caps on, we’ve gone back to the Alma Ata Declaration of 1978 and its position within the decade of the “New International Economic Order” (NIEO). This has helped us begin to understand how the term “PHC” (as distinct from primary care) arose and took on political, social, economic – and moral – significance in global health history. Here, Cueto and his colleague Fernando Antonio-Pries Alves are helpful. They make the strong argument that, while Alma Ata is often seen as a celebratory “founding event” in the development of public health approaches in countries like Brazil, it could instead be seen as an “event that ended a phase of development thinking” that extended from the aftermath of World War II until the oil shocks of 1980. Alves and Cueto describe how the NIEO and Dag Hammarskjold Report promoted self-sufficiency and technical cooperation of countries (especially those recently independent from colonial rule) through economic reforms. In this sense, Alma Ata was actually one of the latest conferences in the “cycle” of international development conferences of the 1970s. Like Alma Ata, NIEO officially offered an “imagined and celebrated consensus”, but in reality it served more as “an area for disputes” than a creator of policy blueprints. Alma Ata and NIEO had a crucial difference, however: NIEO mostly dealt with economic relationships between nation states, whereas Alma Ata was fundamentally about social justice and development decisions within nation states.
Expatriate advisors of the Refugee Health Unit, early 1980s
Indeed, the Director General of the WHO, Halfdan Mahler, wanted to support a “new development order in a socially irrational world”, with a focus on equity and the social determinants of health. Thus, crucially, PHC was defined in terms of both levels of care and approach, with a national self-determination focus. It is the levels of care interpretation (e.g., the first point of care in terms of medical services, or primary care, secondary care, tertiary care) that is often marshalled, especially by actors like the World Bank. But its approach was the heart of PHC: universal accessibility and coverage, community and individual involvement, intersectoral action for health, and appropriate technology. These principles were based on the fundamental understanding that good health requires social justice and accountability. As the WHO argued, resource redistribution could be used as a “litmus test for political commitment” to PHC.
By the mid-1980s, Mahler lamented that the PHC agenda (as espoused by Alma Ata and the Health for All by the year 2000 slogan) had been consumed by “fighting all sorts of conceptual alligators” in a swamp of neoliberalism. In the 1990s, the WHO specifically identified how PHC has often been misinterpreted as:
We can cautiously begin to see the Refugee Health Unit as a response to the ideas espoused by the NIEO and Alma Ata. We’re conducting interviews with Somali stakeholders about its origins in 1979 to better understand how much its ideological underpinning related (or didn’t relate) to the short-lived community health worker-based PHC programmes that arose in the late 1970s to early 1980s in places like India, Colombia, and Sri Lanka. What has struck us is how deeply invested the Somali government was in the Refugee Health Unit – including developing its own standards for the humanitarian system in Somalia, establishing essential drug lists and medical guidelines for refugee camps – and how fiercely its young medical leadership supported the model of community health worker training among refugees. This seems to us to be very different from PHC as designed by NGOs.
Medical team members working with the Refugee Health Unit
Our research has raised a major question, to which we do not yet have a full answer: is the Refugee Health Unit best considered within global health history, or is there something exceptional about PHC within emergency medical assistance that makes it deserve its own historical attention? Van Damme et al., for instance, have stated that PHC and emergency medical assistance are “two fundamentally different strategies for delivering health care”. Was there a time in the 1980s when Van Damme’s conceptualisation could have been different? Does the Refugee Health Unit offer a cautionary tale about involving the government in humanitarian medical settings (the programme largely fell apart with the 1987 war), or does it offer a glimpse into how Alma Ata’s principles could be integrated into practice in an emergency setting with political will? How does memory relate to power and policy in humanitarian medicine?
Stay tuned in the coming months as we unpack these questions further, both on this blog and in papers! For now, we’ll leave you with some inspiring (or perhaps depressing) words from Alves and Cueto: in the 1980s, “with the general crisis in capitalism…the possibility of a rational solidarity between the states and among classes was radically replaced by the logic of the market…in this environment, primary health care, as originally conceived in a generous and radical way, became a flag for resistance”. It may be productive to read current news stories about PHC from such a critical perspective of resistance.