WHEN SHARING THE FOLLOWING REFLECTIONS on the strategic alliances that the People’s Health Movement (PHM) and the Latin American Social Medicine Association (Alames) have forged, we cannot ignore that we are living intense political processes in Latin America, characterized by open-ended, massive popular mobilizations that confront the return of repressive mechanisms and coups d’état that bring back painful memories of the repressive methods and institutional ruptures of the last dictatorships. Alames shows support for the people’s struggle and for the victims of repression and urges the governments of the region to democratically resolve the legitimate requests for more social justice from the people of our region. This is a substantial confrontation that entails the dispute between health as a right or health as merchandise.

In this context, we are also deeply hurt by the death of our colleague David Sanders, founder of PHM. David was the embodiment of the several interactions that have existed between these two institutions for almost two decades.

Alames was created by nuclei that had been studying the prolific interaction between social sciences and health, inspired by university, peasant and worker’s movements from the late 60s and early 70s that soon faced a series of military dictatorships and authoritarian governments that befell the region. In this difficult context, an association with a strong Latin American identity was formed, based on a synergy between a scientific and theoretical production which is highly influential on the region’s way of considering healthcare and a political practice set on complex contexts of substantial inequalities.

This can be explained from the fact that Latin America is, without putting it mildly, if not the poorest region, the most unfair and inequitable region of the world.

In other parts of the world, there was also a real need for improving healthcare, which was starting to be faced with experiences of different depth and breadth. This need was discussed in the declaration of Alma Ata in 1978, which introduced the Primary Health Care (PHC) worldwide as a strategy to achieve a substantial improvement in the people’s situation, expressed in the idealist goal ‘Health for All’.

This strategy collected and systematised previous innovative experiences from different parts of the world, combining ancestral wisdom, community workers, appropriate technology and social and political processes in regions, countries and communities that were distant from each other.

As the end of the millennium approached, there was a growing conviction in different groups of the world about the failure to achieve the goal ‘Health for All’, which consisted in a communicational strategy to spread the main values that placed health in the broadest plexus of human rights.

This new foundational moment that started in Bangladesh in December 2000 may be explained from the figure of Halfdan Mahler -Director General of the World Health Organization during the period in which the Alma Ata Conference took place. ‘Primary Health Care fared better than Health for All’, since it was one of the most used ways to complain about the instrumentation of this multiform strategy which had just adjusted to the mild health care reforms, but which, considering equality results, had not had an impact on the main indicators.

It was not about ignoring the demographic improvements in some countries and regions or the significant growth of what could be called the prioritisation of healthcare systems with a primary level of greater breadth and resolutive abilities which were observed in 2000 and are observed nowadays, it was mainly about remembering that PHC was a strategy, an agenda, of social, environmental, political and health reforms to make the right to health an indivisible part of a fairer world.

On a not so well-known presentation Mahler¹1 Mahler H.Liderazgo y Equidad en Salud, Conferencia inaugural del Centro de Investigación y Desarrollo en Salud. El Salvador: Universidad de El Salvador; 2003. made in 2003, he reasserted the original path when he stated the following:

And he also stated that:

It is probably this conviction which gives rise and meaning to the movement for the people’s health. This founding idea is the translation of a simple phrase attributed to Mahler himself: ‘The right to health is never going to be gained and sustained if it does not arise from a cause carried out by the people themselves’. During the first Conference for the People’s Health in Bangladesh, a new global political fact affected the world’s health system. It was the accumulated and political evidence, masterfully quoted in the Declaration of People’s Health²2 People’s Health Movement. Declaración para la Salud de los Pueblos [internet]. 2000. [acceso en 2019 nov 1]. Disponible en: file:///D:/Revista/Downloads/2000-M1-Declaracion_para_la_Salud_de_los_Pueblos.pdf.
file:///D:/Revista/Downloads/2000-M1-Dec... during the first conference in 2000 and the demanding voices of the growingly excluded people which shaped Mahler’s statements, which were ahead of their time:

Despite the distance, this event could not go unnoticed for our region, which made a conclusive political gesture by celebrating the second World Conference in the City of Cuenca, probably the scenario in which the strategic alliance between two equal and different organizations, united to enforce the right to health and with different but complementary organizational ways, strategies, alliances and ways of political expression was captured.

During the second conference of the PHM in Cuenca, the main organizational instruments were defined, based on the conceptual, ideological and political principles contained in the Declaration of Bangladesh/2000: The People’s Health Movement (PHM) and the International People’s Health University (IPHU).

On their part, by the beginning of the millennium, Alames had forged a strong collaboration with the International Association of Health Policy (IAHP), to the extent that they scheduled their conferences every four years to consolidate their alliance. The IAHP showed a predominantly European perspective in their meetings, while the PHM managed to capture, canalize and express the main concerns of Africa, Asia and the Middle East.

The establishment of bounding mechanisms carried out by colleagues from the General Coordination of Alames, such as Mauricio Torres, Rafael González, Mario Rovere and Alicia Stolkiner were included in several meeting points and mechanisms. However, there were other developments that took place and continue to take place to achieve more sensitivity and convergence regarding the agenda.

As it occurs in these cases, the PHM gradually created its own membership in Latin America, which, far from being a setback, constituted an opportunity to create bonds on a more reduced scale, generally showing the colours of national and subnational difficulties.

The Latin American Social Medicine did not fully appreciate Primary Health Care as it was implemented in several countries of the regions, partially because it became an extremely lax concept, adjustable to every situation, which did not properly differentiate the rewardable or simply palliative aspect of different health interventions, some of them complementary, others contradictory, which were carried out under its name. It was as soon as 1985 when Mario Testa³3 Testa M. Atención primaria o primitiva de salud. Cuad. Médico Soc. [internet] 1985. [acceso en 2019 nov 1]; (34):1-8. Disponible en: http://www.trabajosocial.unlp.edu.ar/uploads/docs/testa__mario__atencion__primaria_o_primitiva__de_salud.pdf.
http://www.trabajosocial.unlp.edu.ar/upl... published his influential work ‘Primary or Primitive Health?’ which alerted for decades about the concrete ways in which the PHC was implemented in a context of an epidemic of dictatorships.

In the same way, the PHM developed a critical mechanism which mainly focused on the operation of the Rockefeller Foundation, only a year after Alma Ata, in its centre in Bellagio, Italy, successfully introducing the didactic debate ‘Selective vs. Comprehensive Primary Health Care’, which is still a controversial issue and contributes to the taking of a position on this lax field.

The characteristics of the political processes during the first decade of the millennium, with eleven countries at their peak for not following Washington’s directives, also had a huge influence. The Basic Health Program, the Mais Medicos (More Doctors) Program and Health Conferences, consolidating a new phase, which is now in charge of the municipality, of Brazil’s Sistema Único de Saúde (Unified Health System), the Health Reforms in El Salvador, Ecuador or Paraguay, the Barrio Adentro Program in Venezuela and the Latin American Medical School (Elam) in Cuba, in which health professionals from all the countries are trained with a strong orientation to General Medicine, were established.

However, the relatively recent concepts which provided more identity to the region, both in PHM and in Alames, may have been the concept of Sumak Kawsay (‘good living’), which may have more influence than in Ecuador, and the notable political, economic and cultural process the current Plurinational State of Bolivia was going through.

The acknowledgement of a new Indo-Afro-Latin American identity occurred as the expression of cultures who had been repressed and silenced for decades and who needed new proceedings of meeting and dialogue to communicate with native people without surreptitiously colonized messages. The political interculturality - which demanded reciprocal value and respect from the cultures who talked and got in touch - discovered a revealing concept different from the relation with nature and life in community.

This is not the reason for this short report, but, in order to express the transformation potential of this concept in one phrase, let us compare the Jewish-Christian commandment prevailing in the west: ‘you will rule the Earth’, with the commandment of the ancestral communities: ‘the Earth does not belong to us, we belong to the Earth’. This is a difference that adopts a dramatic tone in contexts in which life’s viability in our planet is threatened.

In October 2018, the Astaná Conference regarding Primary Health Care, forty years after Alma Ata, represented a new reason to gather, to unite the different.

Regarding the differences that will probably be poorly expressed in the ‘confrontative incidence’ or ‘collaborative incidence’ pair, Alames has frequently chosen a confrontative incidence strategy with the WHO, as it was noted during the heated debates regarding the implementation of a social determination system of health or of social determining factors of health, as a reaction to the process of the badly named ‘Marmot Report’, which ignored 25 years of Latin American production.

The PHM, on its part, probably because it had the advantage of counting with a former Director of the WHO, chose a closer approach, trying to force the WHO into a certain accountability and trying to influence with the use of documented instruments such as the follow-up to Health Conferences and meetings or the publication of the Global Health Watch.

In the face of the intention of the WHO, the World Bank and the Government of Kazakhstan to hold another meeting to end the controversies - a year after the death of Mahler - the critical position arose again immediately, the main convergence of which was the declaration in the preparatory documents that attempted to include Primary Health Care to the controversial Universal Health Coverage (UHC).

However, it can be perceived once again that there are differences and complementation, since Alames published a critical document even before the meeting took place, based on the provisional documents of the WHO itself, while the PHM managed to take part in the meeting, explaining its critical position on the debates.

The challenge for the oncoming years is to find a way to delve into the shared agenda, to multiply the number of meetings and the number of members involved in this dialogue which deals with people from all over the world, people with so different languages, traditions and cultures, but who share decades, if not centuries, of resistance towards an international, depredatory and exploitative capitalism that intends to destroy our identities throughout a deceiving globalization by imposing its consumption models.

The rights of Mother Earth, the rights on internal and external migration, the rights of war or environmental refugees, the international fight against the patriarchy, the young people’s movements against climate change and the need for a strong decolonization of our societies and our governments is still an issue to be dealt with to guarantee the right to health.

The generous giving, the understanding attitude despite the cultural barriers, the cordiality and the life testimony of David Sanders are other motives to improve our agenda, to boost our strategies and enhance the bonding between Alames and the PHM.

Acknowledgements

We thank Mario Rovere for his contribution to the elaboration and final revision of this document.

References

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