Thursday, February 15, 2018

Limits to Growth, the Rohingya, and Planetary Health

I wrote the following for a conference on "planetary health". It was rejected (no feedback). I may as well post it here.  The writing is compressed, due to the word limit. I have added a brief commentary. Comments welcome, as always.

Introduction and Background

Numerous violent expulsions and panicked flights of the Rohingya, a minority population mainly from Rakhine state in Myanmar, have been documented since the 18th century, but their incidence and scale have increased since 1978. Of a population estimated at 1-1.3 million, over 700,000 Rohingya fled Rakhine in late 2017, joining hundreds of thousands of Rohingya already living in exile in squalid refugee camps in Bangladesh. (1) The 2017 expulsion of and flight by Rohingya is the largest yet. Although Rohingya-led violence is well-documented (2) many argue that the response of the Myanmar state is grossly disproportionate. The adverse health effects of this violence and exile are immense, profound, diverse and multi-generational. (1,3) They may arise from social responses to deteriorating physical ecology.


Rakhine is fertile, but growing tension over resource distribution, (4) combined with weak institutions and population growth, have been identified as likely to contribute to human insecurity in Myanmar. The 1994 Rwandan genocide has been postulated as an “eco-social” phenomenon, arising from growing resource scarcity interacting with social ecology, expressed as fear of the other, racism, and entrenched beliefs and behaviors, expressed by both victim and perpetrator groups. (5) It is here theorized that many subtle changes, as yet poorly studied, in the physical ecology of Rakhine have contributed to the plight of the Rohingya. As in Rwanda, a dynamic of competing social ecologies has generated violence, on a background of real and perceived resource scarcity.

Many vested interests inhibit resolution, and even diagnosis of this chronic health emergency. The most obvious obstacle is the hostility of the dominant Buddhist population in Rakhine, supported by an aggressive central government and military. United Nations Security Council action is inhibited by China, which shares with Myanmar anti-democratic impulses and practices. (4)

Diagnosis and remedy of the Rohingya crisis is also inhibited by dominant neoliberal academic discourse, which for decades has suppressed and failed to integrate the multi-disciplinary evidence that underpin and explain the growing planetary heath emergency. (5) Two particularly important strands are approaching limits to growth (6) and the once widely accepted view that rapid population growth generates and entraps impoverished populations. (7)

In response to the most recent crisis, the United Nations High Commission for Refugees has helped to fund Rohingya camps, supported by many aid groups, such as Médecins Sans Frontières. (1) There has been much criticism of Myanmar authorities, especially from Western sources. Inevitably, however, these criticisms and attempts to assist, even if noble, can do little to solve the really deep causes.


Although aggression, fear, violence and hatred have deep evolutionary roots, a future can still be created in which populations, even if culturally diverse, such as in Rakhine, live in partial harmony, or at least co-exist. Implementation of these solutions has several pre-conditions. These include a global re-awakening, both high-level and distributed, that the scale of human co-operation needs to be widened to the planetary level, and an evolution of technology which allows the worst physical manifestations of adverse environmental change to be kept within tolerable levels.


It will be interesting to see if the Planetary Health conference includes any papers on the Rohingya, and for that matter, any of the many other cases of what I have called "regional overload".  I am rather doubtful. In 2016 I was invited to submit a longer version of these arguments for the first issue of the new journal Lancet Planetary Health - but only if accompanied by US$5,000 (for a research paper, not a commentary). In a world of intensifying market forces, where publishing is corrupted by money and power, this is not surprising.


1. White K. (2017) Rohingya in Bangladesh: an unfolding public health emergency. Lancet 390:1947.

2. International Crisis Group. Myanmar: A new Muslim insurgency in Rakhine State (2016)

3. Riley A, Varner A, Ventevogel P, Hasan MMT, Welton-Mitchell C. (2017) Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcult Psychiatry 54(3).

4. Kattelus M, Rahaman MM, Varis O. (2014) Myanmar under reform: Emerging pressures on water, energy and food security. Nat Resources Forum 38(2):85-98.

5. Andre, C., Platteau, J-P. (1998) Land relations under unbearable stress:Rwanda caught in the Malthusian trap. J Econ Behav Organizn 34, 1-47; 75. Butler C.D. (2000): Entrapment: global ecological and/or local demographic?Reflections upon reading the BMJ's "six billion day" special issue. Ecosyst Hlth 6, 171-180.

6. Bolopion P. (2017) How long will UN Security Council be missing in actionon Burma? New resolution opportunity for Council to address crisis. Human Rights Watch.

7. Butler C.D. (2017) Limits to growth, planetary boundaries and planetary health. Current Opinion Envtl Sustainability 25: 59-65; Butler C.D. (2017) Regional overload, and the consequences it has for health. BMJ; Butler C.D. (2016) Planetary Overload, Limits to Growth and Health. Curr Envtl Hlth Reports 3(4): 360-369; Butler C.D. (2016) Sounding the alarm: Health in the Anthropocene. Int J Envtl Res Pub Hlth 13, 665

8. Butler, C.D., Higgs, K. McFarlane, RA. Environmental health, planetary boundaries and four futures. In Bachmann, T. (editor) Encyclopaedia of Environmental Health, Elsevier (submitted).
9. Butler C.D., Higgs K. Health, population, limits and the decline of nature. In: Marsden, T (editor) The Sage Handbook of Nature (in press).

Sunday, February 4, 2018

The Wizard and the Prophet: overstating the gap?

The author Charles Mann has written a book called The Wizard and the Prophet, about Norman Borlaug (1914–2009), who he calls the "wizard"  and William Vogt (1902–1968), an ecologist Mann calls the "prophet". Vogt, in turn, inspired the young Paul Ehrlich. (See for example, the highly critical artlcle called "The Post War Intellectual Roots of the Population Bomb" published in the Electronic Journal of Sustainable Development, which I criticised in 2009, for its libertarian funding (see PPS).

I have read two reviews of Mann's book (in Nature and in Science) and a short essay by the author in the Atlantic Monthly.

But none of these make clear that Borlaug (an agricultural scientist who was instrumental in developing the Green Revolution, which enabled much higher crop yields, albeit usually requiring more fertilizer and water) was, in my opinion, deeply concerned re population and limits. 

In his Nobel Prize acceptance speech (1970) Borlaug said:

"It is true that the tide of the battle against  hunger has changed for the better during the past three years. But tides have a way of flowing and then ebbing again. We may be at high tide now, but ebb tide could soon set in if we become complacent and relax our efforts. For we are dealing with two opposing forces, the scientific power of food production and the biologic power of human reproduction. Man has made amazing progress recently in his potential mastery of these two contending powers. Science, invention, and technology have given him materials and methods for increasing his food supplies substantially and sometimes spectacularly, as I hope to prove tomorrow in my first address as a newly decorated and dedicated Nobel Laureate. Man also has acquired the means to reduce the rate of human reproduction effectively and humanely. He is using his powers for increasing the rate and amount of food production. But he is not yet using adequately his potential for decreasing the rate of human reproduction. The result is that the rate of population increase exceeds the rate of increase in food production in some areas" (italics added).

Toward the end of his life, in 1992, Borlaug co-signed the first World Scientists' Warning to Humanity, something Vogt would have approved of.

P.S.  Many articles and at least one other book are in this genre, comparing the highly optimistic “cornucopian” Julian Simon against both Paul Ehrlich and Norman Myers

P.P.S. The journal's website is difficult to follow, but the full text of Vol 1, issue 3 can be downloaded for free from Research Gate here. But even there you have to hunt a bit for it - you land on a page that says "Land Conflict and Genocide in Rwanda".

Sunday, January 21, 2018

Climate change, heat, and a possible risk to infant and child health

I recently wrote to warn that players and spectators at events such as the Australian Open may unknowingly be placing their future as well as short term health at risk, due to exposure to levels of heat (up to 69 degrees C in the sun on the court enclosed by a vast stadium) which I think are unacceptable, particularly for players engaged in the most strenuous exercise that is imaginable. 

I also warned that some spectators, many of whom are far less fit and most of whom are older than the players, may also be at risk, even if not exercising and even if they are well hydrated.

But I would like to add that there is also a theoretical risk that pregnant women may be putting their unborn babies at risk, both in the womb and after birth, perhaps lifelong.

This hypothesis is plausible if the link between season of conception and foetal deaths is confirmed to be in part due to heat exposure. While that is currently uncertain there are suggestive data in support, such as an econometric paper. This found that additional days above 80°F (26.7°C) causes a "large decline in birth rates approximately 8 to 10 months later". The authors comment that air conditioning could be used to substantially offset the fertility costs of climate change, a suggestion which is unfortunately as yet too expensive for most of the world's people.

Pregnant women watching events such as the Australian Open, especially in very hot days and even more so if they are sitting in the sun, may therefore risk having a miscarriage. 

However, that is not the only risk. If we hypothesise that a certain "dose" of heat, a metric that combines air temperature, humidity, duration of exposure, clothing and exercise can lead to foetal death, then it follows that a lower dose of heat may cause subtle or even gross foetal abnormality, in infants exposed to a lower dose in utero. This would be analogous to my hypothesis, which I first originated in 2012, that frail, elderly and in other ways vulnerable people who do not die of prolonged heat exposure are likely to suffer from other effects, some of which could be long-lasting, especially if they accidentally fall during a period of recovery.

Furthermore, if there is a threshold of a heat "dose" then it is highly unlikely that one size fits all. The dangerous dose is likely to be influenced by many other factors: age, fitness, weight, other indicators of health status, genes, and perhaps, even month of birth. It is also likely that some stages of pregnancy are more vulnerable than others.

It has long been known that being born in autumn confers a higher life expectancy than being born in spring (at least in non-equatorial regions that have distinct seasons). Could heat in the first trimester be an under-recognised factor helping to explain this?

Of course, this is only speculation. It would require a great deal of study to be more sure. But, since 2012, research funds to study this and similar questions have been virtually unavailable in Australia. 

My recommendation to the organisers of the Australian Open is to hold the tournament in a later month. But that suggestion won't be taken seriously for many more years. For spectators who are pregnant or possibly pregnant - I suggest that they sit in the shade and drink lots of water. Wear a hat and bring a fan. Or perhaps consider staying at home if the temperature is too high. Yet, no one knows what temperature is too high. I suggest the risk is likely to be higher with higher temperatures and the relationship is likely to be non-linear, i.e. the additional risk between 43 °C and 42°C is likely to be more than between 21°C and 20°C. And, please, lobby a politician to treat global warming and climate disruption with the seriousness it deserves.

An early premonition: Sikkim, 1988

In 1987 (before BODHI was formally started) I was invited, with another Australian doctor, to visit Rumtek Monastery, in order to explore establishing a clinic there. We had a letter of invitation from the secretary of Tai Situ Rinpoche, one of the four "seat holders" caring for the Kagyu lineage while disciples waited for the reincarnation of His Holiness the Karmapa.

Rumtek is in Sikkim, then a restricted state of India, with only 3 days maximum permits being issued.

We applied at least 3 months in advance for the permit to go to Skikim. At that time of my life, being trusting, and also anticipating a long relationship with India, I thought it prudent to be absolutely honest, so my stated purpose was not tourism but something like “to discuss establishing a clinic”.

We were granted a visa, but no permit. We were told we might get the permit after arrival in India. In Kolkata (January 1988) we went to the famous “Writer’s Building” where clerks were dwarfed by vast piles of paper (few computers in India then). We were told, “no permit but you might get one in Darjeeling". We went to Darjeeling. There, a friendly official said “yes, you can have a permit - would you like one for 7 days?) (i.e. greater than twice the normal).  Well, we couldn’t, because we had booked a train to head towards Bodh Gaya, a few days later. But 3 days was fine.

Overjoyed, we caught a bus to Gangtok (Sikkimese capital). We arrived in the evening. Next day we explored Gangtok, waiting for the bus to Rumtek (about 15 kms away). With hindsight, I think the local police may already have been looking for us.

Gangtok: source

We caught the bus. We arrived at dusk. I felt exuberant. We were welcomed, we were fed. After about an hour at Rumtek I had one of the few genuine premonitions in my life, as if I could feel a shadow. Perhaps a minute later, four police arrived. They took us back to Gangtok. Its lights were strewn like stars on the hill across the valley. The police allowed us to sleep in a hotel that night, but we had to report to them the next morning and then stay continuously with them, although we were not formally arrested. Then they took us to board the commercial helicopter (at our own expense) back to Bagdogra, the airfield on the plains below Darjeeling. The only consolation was that the helicopter’s route was via western Sikkim, then completely off limits to tourists. We saw a famous golden monastery from the sky, probably Pemayangste. The governor of Sikkim was also on board. The police were quite excited about that, they said it was auspicious, and signified we would one day return.

When we eventually reached Delhi, we spent another day in a queue; eventually we saw an official. She was initially sympathetic. But then she found a file, and her attitude changed. She told us absolutely nothing. An official at the Australian High Commission also told us nothing.

I have not yet been back to Sikkim, I have not tried.

Friday, January 19, 2018

Climate disruption, extreme heat and sport

In recent weeks sportsplayers and health have been in the news. Last month, Suranga Lakmal, a fast-bowling cricketer from Sri Lanka, vomited in New Delhi, on field, due to air pollution and exercise. This month (January 2018), English cricketer Joe Root retired ill, due to diarrhoea and extreme heat. Kato Ottio, a New Guinean rugby player died this month, after falling ill at football training. Cycle races in Adelaide have been truncated or rescheduled due to multiple days with shade temps in the mid-40s.

And this week, at the Australian Open, tennis players and tennis spectators are being exposed to unacceptable levels of heat with surface temperatures, in the sun, on some courts, approaching 70 degrees C. I am no expert in building design, but several factors turn the main stadium into a heat trap. The centre court is enclosed in all directions by ranks of seats, has a roof, and gets zero, or very little ventilation (especially if the roof is closed). The enclosure has enormous thermal mass and the court is laid on concrete. In addition, each spectator is itself a producer of heat (about 100 watts per person, continuously.) (see PS for how to improve this design.)

I am sorry but it is time to reschedule the summer cricket, cycling and tennis to a cooler month, and similarly, time to recognise that dangerous climate change is no longer in the future. Climate disruption is here. Shifting the dates would be a form of adaptation. It would leave a big hole in our summer,'s entertainment, but it is unacceptable to treat athletes as guinea pigs for the pleasure of spectators, watching at home in air conditioned comfort. (That is, if the air conditioning and energy infrastructure can keep up.)

What we know about heat and health

There is a fair bit known about heat, humidity, the wet bulb temperature and that fit young men and women can easily die of heat stress. Dogs pant and elephants flap their ears in extreme heat; humans sweat. When sweat evaporates we lose a little heat, lowering our core temperature. We also have long known that humidity greatly increases the danger of heat, as in humid environments our sweat does not easily evaporate. Thus, sweating when it's humid is not as effective.

If the wet bulb temperature reaches 35 degrees C. then even a fit person will die, probably in just a few hours. Such wet bulb temperatures are still extremely rare, but by treating our atmosphere as an open sewer, as recommended by a legion of politicians, we are on track to make some parts of the world completely uninhabitable if we go outside. If you are not fit, you will probably die even sooner, and at wet bulb temperatures below 35 deg C.

We also know that people with pre-existing illnesses are more vulnerable to acute heat effects, manifesting within minutes, hours or perhaps days. We know that in the 2009 heatwave in Victoria, where 173 people died in bushfires, even more died in Melbourne from simple heat exposure. (See the Victorian Department of Health report.)

Acute (rapid onset) symptoms can be reduced and hopefully prevented by drinking, cooling and stopping exertion. Sports people can drink, apply ice, and maybe even have the roof lowered so there is shade - but they can't stop their exercise without losing.

Heat can, in some locations, especially cities, elevate exposure to troposphericic (low-level) ozone (mainly from traffic), which harms lung function.

We have virtually no idea of the long term effects of excess heat

In contrast to the knowledge on acute exposure to extreme heat, we know next to nothing about the long term effects, other than some data on renal impairment and urinary tract stones due to prolonged dehydration, mainly affecting agricultural workers with inadequate water access. We also know a little about sudden, often mysterious deaths in exploited construction workers, particularly in the Middle East. But we know next to nothing about the life expectancy and other health indicators of those workers who do survive. (And we are not likely to - their employers will not welcome such studies.)

The starting position of those running the Australian Open appears to be that if a player or spectator survives symptomatic heat stress then their future health will be completely unaffected. But this may be wishful thinking. We don't even know that if someone who experiences extreme heat exposure, but is completely without symptoms, will be ok in the long run.

In fact, the converse is more plausible. It is, for example, highly likely that those who are vulnerable to heat (such as the elderly and those with pre-existing conditions, e.g. heart failure, dementia or many other severe chronic diseases) who do not die will have a step-like fall in their function, at least temporarily. Will they recover that full lost step? Over what period? How many will have a mishap, such as a fall, before they fully recover, in the weeks or months after the heat event? In the elderly, falls can be very serious, and often presage death.

It is also well-known that many multiple sclerosis (MS) patients experience a decline in function during heat - heat slows nerve conduction. Could excessive heat tip some people, previously unaffected, into neurological conditions, including migraine? (French tennis player Gael Monfils reported extreme dizziness at the Australian Open). We don't know. We do know that people at higher latitudes have more MS. The dominant explanation is that such people are exposed to more ultraviolet light, but could a factor be that, in part, over long periods of time, such people have sought to live in cooler conditions? Or perhaps that those with MS in very hot areas aren't able to have the same reproductive success?

Extreme heat also has harmful effects on unborn children

Human bodies can be thought of as complex mixtures of chemicals and electrical signals. We have evolved to live in an "envelope" of temperature and humidity, an envelope many people are now exceeding. How do we know that proteins (or any other bodily component) repeatedly exposed to high temperatures will completely recover? Is that plausible?

"The healthy player effect"

Sure, we see champions like Roger Federer appearing to function well, despite the heat. But could there be a "healthy player effect"? That is, might we not learn a lot more about the adverse effects of extreme heat upon sportspeople by studying people who abandoned sport, or perhaps switched to a winter sport, due to their discomfort with heat? My former mentor, Tony McMichael, coined the term "healthy worker effect", recognising that studying the health of long-term factory workers told only a small part of the story.

The NH&MRC's failure to recognise the risk of chronic heat effects

Between 2012 and 2016 I repeatedly proposed research projects to investigate aspects of these questions, but with no success. The National Heath and Medical Research Council has declined to fund at least six large grant applications of relevance. (I was involved with five of them, one of which I led).


It is unconscionable to treat athletes and spectators in hot conditions as guinea pigs. Many emergency workers such as firefighters and military personnel have to endure such heat. We urgently need to better understand the long term risks that those workers face, and, if we find them, then try to work out ways they can be protected. However, until we know, spectators and athletes will be better protected by a change in the date of the Australian Open, cycle races, and in the near future, cricket.

Decades of denial and neglect about climate change, such as by former Australian Prime Minister  Tony Abbott (a keen cyclist), have created this crisis. Let us not compound that negligence. Ignorance is no defence. We have a duty of care to investigate chronic health effects of heat. I have a duty to add my voice about these many concerns.

PS A correspondent has suggested that the stadium could be retrofitted to have water flowing through tubes under the court to extract heat from the slab, and possibly the stands, circulating it for other uses. If the roof were closed and the air conditioning turned on, the mass cooling would possibly use less energy that individuals if they were at home turning on their air conditioners. A greater use of solar panels would lower the greenhouse gas footprint of the stadium, offset the carbon emissions the complex uses from the grid (as Victoria still uses mainly coal-fired power), and create good will.

However, some observers may claim that a cooled stadium would give an unfair advantage to players (especially higher ranked seeds) who are more likely to be chosen to play on that court. 

About the author

Adjunct Professor Colin Butler graduated in medicine in 1987, and has four post-graduate degrees or diplomas in public health, including a PhD in epidemiology and population health from the Australian National University (awarded in 2002). He also has over 10 years of clinical medical experience, mainly with elderly, disadvantaged patients, in the Australian state of Tasmania. He is one of only two living Australian contributors to the health chapter of the most recent IPCC report.

In 2014 he became the first Australian IPCC contributor to be arrested for civil disobedience about climate change, attempting to draw more attention to this crisis. He is sole editor of the book Climate Change and Global Health (CABI, 2014). In 2010 he was awarded a Future Fellowship by the Australian Research Council, allowing 4 years of independent research on topics related to global environmental change and health. He has experienced hate mail and an official complaint to his former university, due to his activism over climate change. His first article on climate change and health was published in the Medical Journal of Australia in 1991.

Wednesday, January 17, 2018

Halfdan Mahler, primary health care, and the warm decade for social justice

This is an expanded version of an article in the (50th) issue of BODHI Times. This is the occasional newsletter of the NGOs BODHI and BODHI Australia which I co-founded in 1989. It is based on several sources, including an excellent open access article by Theodore Brown, Elizabeth Fee and Victoria Stepanova called "Halfdan Mahler: Architect and Defender of the World Health Organization “Health for All by 2000” Declaration of 1978".

A pastor's son, "disease palaces" and the origins of primary health care

Dr Halfdan Mahler, who died in December 2016, was the third Director-General of the World Health Organization (WHO). Brown et al summarise his development: "The youngest child of a Baptist preacher, Mahler chose medicine over preaching." After training in tuberculosis care and prevention "he led the Red Cross campaign against the disease in Ecuador, before joining WHO in 1951. Experience in India convinced him that public health resources in developing countries were biased toward hospital-based medical care and that these priorities had to change."

Socrates Litsios, in a long personal reflection on primary health care and Health for All provides two relevant anecdotes about Mahler, one about the unfair distribution of health resources, the second about the difficulties of reform (see green).

Mahler related the example of a developing country in which health was declared as “a   universal human right” but in which one found, in one province, “80 per cent of the health budget being used to support one teaching hospital, whereas in outlying parts complete coverage is supposed to be achieved by one general purpose dispensary for half a million people.”
"During his work in India, Mahler had become convinced that tuberculosis could be successfully treated with ambulatory (non-hospital based) care: “[we went] with tears in our eyes, to the Minister and we said ‘Madame Minister, now that we have shown this you will have to close down all your tuberculosis hospitals because we need the money in order to do ambulatory kind of treatment’ and she looked at me and said ‘you must be a crazy man, even an elephant would cry over your naivete. How do you think I as a politician can close down the hospitals, you must be mad’.”

Mahler before a Mercator's projection; an unfortunate choice, given his dedication to social justice!
Primary Health Care, Disease Palaces and David Morley

A term reflecting the problem Mahler had perceived is "disease palaces". Popularised (and probably coined) by another Christian, David Morley, this refers to the disproportionate concentration of health resources in one, or perhaps a handful, of fairly elaborate hospitals, in countries which are overwhelmingly poor. The problem is not that a poor nation should not have a halfway decent (or even a good) hospital; it is that the amount of human and financial capital that such a hospital demands leaves little (from the health budget) for basic sanitation, nutrition, health education and other aspects of primary health care. More background about disease palaces is in Morley's book "Paediatric Priorities in Developing Countries". Published in 1973, the same year that Mahler was elected as WHO Director General, it too is a product of what Mahler called “a warm decade for social justice".

I never had the fortune to meet Morley, but I acquired and read his book in 1985, the year I focused on the study of health in what was then still largely called developing countries, including by participating for several months in health care in hospitals and remote rural settings (sometimes mobile) as a medical student in northern Nigeria and eastern Nepal. Another influential book was Maurice King's "Medical Care in Developing Countries". I have met Maurice several times, and in 1992 he became BODHI's public health advisor.

Primary health care (PHC) at its simplest, is "the place of first contact with a national health care system". In some countries, especially those that are poor, this means, for the overwhelming majority, health care that is not "tertiary", that is, not hospital-based. Using this definition, PHC need not be sophisticated, and can be delivered not only by people without university training, but without finishing high school. The most famous example of this were China's "barefoot doctors", whose actual benefit is hard to assess, due to the fog of propaganda.

Primary health care horror stories

Care delivered by barefoot doctors and their equivalent, at no or minimal cost to the patient, is obviously cheaper to provide than via medical schools, pharmacists, or properly trained nurses. In many poor settings, it may be better than fee for service alternatives, even if provided by supposed professionals. When I was more involved with the practical aspects of this topic (between 1985 and 1996) I heard horror stories of the financial abuse of patients (mainly in India and Nepal) by health professionals. 


An example I recall is of people with suspected tuberculosis (TB) travelling to a town for a chest X-ray when a sputum examination (at least in skilled hands) is more accurate and useful, and far cheaper. In low income settings (at least then) a chest X-ray, a test whose cost is modest to most readers, could lead to debt (not to mention the travel and foregone income from not working that day).

Also, as is still fairly common, powerful antibiotics were easily available over the counter (i.e. without a doctor's prescription). The risk of such self medication - especially for TB, which requires months of treatment - even if involving rifampicin - is of developing drug-resistant TB, which is an even more expensive and dangerous public health issue. This problem may be less now, due to DOTS - Directly Observed Treatment (short course), which was introduced to reduce this problem. 

In 1994 I spent one harrowing day seeing about 40 Tibetan refugees, as patients, in a camp in South India. Several were on "third line" anti-TB drugs. These third line drugs are expensive, have a high risk of severe side effects, and are not very effective. Patients get put on these drugs generally because the TB bacteria they harbour have evolved resistance to more effective drugs, because the patient did not take them for long enough (many months). The risk is that such resistant bacteria will cause a primary infection in a patient, such as a child, or even a friend or relative who has previously been cured. If it does, that child could be virtually untreatable, and so will the adult.

The possibility that the successes of PHC are over-stated

Ethical and appropriate care by barely trained community and village health workers cannot be guaranteed, and may well be uncommon, despite its supporters, who may "cherry pick" overlooking failures and exaggerating successes. Such care may be adequate for some health problems, many of which get better without treatment or proper diagnosis. Barefoot or village health care workers can also, in some settings, make simple diagnoses, give advice on hygiene, monitor infant and child growth and treat and prevent conditions such as diarrhoea. They might also apply first aid, administer vaccines, and treat a variety of other conditions. 

On the other hand, especially in very low income settings, many people do have significant underlying health conditions, not just TB, but depression, hypertension (very common in some low income settings, perhaps related to undernutrition in childhood) and chronic parasitic infections such as hookworm or schistosomiasis. (Note: hookworm can be easily treated but re-infection is common, where footwear and hygiene are poor, especially from a lack of toilets). 

I met some community health workers, in India, also in 1994. I felt very sorry for them; they had low status, were young, and appeared completely overwhelmed. There are many limitations to the effectiveness of primary health care but its promise to provide an affordable basic underpinning of health for the poor, especially in rural and remote settings, in ways that hospital based care cannot, was alluring, for a while. My personal experience also made me sceptical about some of the claims in David Morley's book. While the village (in Nigeria) he worked seemed a model of success, I was concerned that this depended too much on his nurse, a European with devotion and skills not easily reproduced and sustained in such settings, though, sometimes, religious faith can provide deep and enduring motivation.

But some primary care groups such as Jamkhed have an excellent reputation. With charismatic and dedicated leadership and support, fairly high quality health care can be provided by people without tertiary education. Such people acquire so many skills over time that they effectively are trained at a tertiary level, at least to the equivalent of a good nurse.

Leading to the "sacred moment" at Alma Ata: back to Mahler

Following the immense global trauma of World War II, so soon after the Depression, WHO and the other UN agencies were bathed in hope.

The struggle between social medicine and technical assistance

However, the inception of WHO (1948) was almost immediately followed by the withdrawal of the Soviets and several other socialist countries, from 1949 to 1957. Fee et al, in a useful recent paper (Nov 2016) in the American Journal of Public Health, trace some of the factors leading to this, especially the sacrifice made by the Soviets in World War II (at least 20 million dead, in comparison the US lost 400,000 troops) compounded by limited assistance to the Soviet Union and its allies, such as via the Marshall Plan. Of course, the US and its allies were both horrified and terrified by Communist beliefs, by its contempt for genuine democracy, by the ruthless purges of dissenters by Stalin and others and by the fact that the USSR was also developing nuclear weapons, as the Cold War progressed.

Some time after the USSR re-joined WHO, Dmitry Venediktov, the Soviet delegate to WHO, and a few others, supported by Mahler, called for a shift in focus by WHO, to better reflect the idealistic post WWII framing of health enshrined in the WHO constitution (see in green).
"Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity".

"the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition".

"governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures ".

Many others in WHO, including Brock Chisholm, the first director-general (a Canadian), hoped that it would still stand by the social medicine principles embodied in its constitution. A key founding member, Andrija Stampar (born in modern Croatia, influenced in medical school in Vienna by Ludwig Teleky’s lectures on social medicine), argued that the WHO should concentrate on 4 principles:

A. social and economic security

B. education
C. nutrition
D. housing.

Taken seriously, a social medicine perspective required questioning the inequality of land ownership in rural areas and the striking inequities, poor housing, misery, and illness in urban areas. However, the United States, WHO's largest funder (at least then) was not interested in this approach and instead promoted the concept of “technical assistance” to the problems of health in what we now call the Global South.

“Technical assistance” conveyed the idea that developing countries were best helped through the transfer of knowledge of science and technology. As many critics have pointed out, this approach bypasses concern with the economic interests and social realities that led to and maintain underdevelopment.
In the 1950s, in its first full decade, WHO had led a massive attempt to eradicate malaria, a clear case of technical assistance. This was inspired by the then recent synthesis of DDT, and the discovery of its almost miraculous insect-killing properties.  It made an enormous difference in India, although most progress there occurred before World War I, which was, actually, the topic of my Master's thesis (at least in the Punjab, which then extended from Delhi right to the Afghan border.)

Fee et al argue that also contributing to the Soviet boycott was a growing conviction on the part of the Soviets and their allies that there were "two dramatically opposing views of public health: that of capitalism and that of communism". This dichotomy persists today.

The election of Mahler: a brief shift towards a social medicine approach by WHO

In 1973, elected WHO director-general, Mahler was able to help channel and shape the political and moral currents of the 1970s. In 1976, early in his directorship, Mahler and WHO accepted a proposal (made by the Soviet Union in 1974) to hold a conference, which was to be called the International Conference on Primary Health Care. In 1977, still led by Mahler, WHO adopted a resolution (WHA30.43) called “Health for All by the Year 2000”.

The conference, which received substantial Soviet support, was held the next year, in Alma Ata, today Almaty, the capital of Kazakhstan, but at that time in the Soviet Union. It was envisaged by Dr. Dmitry Venediktov, then Soviet deputy minister of health, to be on the same scale as the World Population Conference, held in Bucharest in 1974, and attended by more than 1400 people. According to Litsios, Mahler opposed this site, but various alternatives proved unfeasible.

This meeting included the statement that:

“an acceptable level of health for all the people of the world by the year 2000 can be attained.” 
The undermining of Primary Health Care

Soon after the "sacred moment" of Alma-Ata, efforts to weaken Health for All began, (and the broad view of primary health care) weakened, as neoliberalism increased in power. I, with Sharon Friel, also published on this in 2006) - it's also open access, in PLoS Med. We wrote:

"All social movements and scientific disciplines are subject to powerful institutional and natural forces that shape their social, economic, political, and environmental milieu .. like the health promotion movement, WHO is also subject to larger forces. Since Alma Ata, the rhetoric, aspiration, influence, and—arguably—the achievement of WHO has diminished, coincident with a decline in many public goods."

Mario Cuteo, in a 2005 editorial in the Bulletin of WHO also sheds light: "In its more radical version, the complete reform of public health structures and the promotion of major social changes were envisaged, with primary care as the new centre of health systems. In contrast, according to an instrumental interpretation, it was merely an entry point, a temporary relief or an extension of services to underserved areas. The latter interpretation could not avoid being perceived as second-class care, “poor” medicine for poor people."

Cuts to the WHO budget: the counter revolution, led by the US under President Reagan

Brown et al note: "Major donor nations, such as the UK and the US froze contributions to the WHO budget. Then, the Reagan administration decided to pay only 20% of its assessed contributions to all United Nations agencies. In 1979, the Rockefeller Foundation sponsored a small conference included representatives of the World Bank, the US Agency for International Development, the Rockefeller Foundation, and the Ford Foundation, which formulated an alternative “selective primary health care” agenda, which differed sharply from the agenda and spirit of Alma-Ata. Mahler’s principal lieutenant in the battle for Alma-Ata was Ken Newell, a New Zealander, whose edited book Health by the People was influential. 

Newell called these efforts a “counter-revolution.” The World Bank, the main international donor for health development, adopted a neoliberal policy of privatizing health services in the 1980s, further undercutting Alma Ata."

Also excellent and relevant in understanding the decline in the vision of Dr Mahler is the book by David Sanders and David Werner "The Politics of Primary Health Care and Child Survival". See this book review by Claudia Shuftan.

Mahler making enemies

Mahler alienated many people. Another anecdote from Litsios is that, when Director General elect, Mahler supposedly advised a “very powerful president of a developing country,” who had asked Mahler what he could do to develop a health care system (which Mahler told him he did not have) as follows: “I think the first step is to close the medical schools for two years. Then we can discuss what the medical schools were supposed to do, because they really constitute the main focus of resistance to change”. 

Back to the future: world health dominance by corporate-derived foundations 

Technical assistance such as to eradicate malaria was revived, but not by WHO in the 2000s. It is again likely to fail, this time in part because of increasing resistance to insecticides used to impregnate bednets, by mosquitoes, rather than resistance to DDT, the breathrough seen as miraculous in the 1950s. 

Mahler and Family Planning

After retiring from WHO in 1988, Mahler became Director of International Planned Parenthood Federation until 1995. Throughout his career, Mahler emphasised the role of women in promoting health. “Women are the raw material for development”, Worning remembers him saying. The economic and health benefits of spacing children has long been one of my own main pleas. I have written dozens of papers about this, but with little obvious result! (e.g. Reflections on human carrying capacity)

Mahler's final plea

Thirty years after the Alma-Ata Declaration, Mahler told the World Health Assembly in 2008: “To make real progress, we must, therefore, stop seeing the world through our medically tainted glasses. Discoveries on the multifactorial causation of disease have, for a long time, called attention to the association between health problems of great importance to man and social, economic, and other environmental factors.”

Looking forward

Although the Sustainable Development Goals may seem as hopeful and aspirational as Health for All, they have virtually no chance of succeeding. In fact, it is all too plausible that we are headed for a new dark age. The presidency of Donald Trump is but one manifestation of deepening inequality. Ugo Bardi, a member of the Club of Rome, has noted that as cheap energy declines, slavery is returning.  Famines are returning and "regional overload" is obvious in a growing number of locations.

A great awakening is needed. We need new leaders such as Jeremy Corbyn, Bernie Sanders (or maybe Elizabeth Warren) - but not neoliberal Oprah Winfrey. We need more vegetarianism and technological miracles. We need more courage in academia and also in the development movement, who are either blind or self-censoring about high rates of population growth in poor countries. We will need a lot of luck, because leadership such as from Mahler is now very hard to find.