The Declaration of Alma-Ata formulated a broad definition of health, proclaimed health to be a fundamental human right, and established programs aimed at achieving universal health by the year 2000.
Public health has been a battlefield of occasional victories and recurring monumental losses throughout history. Famine and plague have left their mark on every generation of recorded history, and certainly on those that came before. The twentieth century offered no exception. For example, more Americans died of influenza in the epidemic of 1918-1919 than were killed in the entirety of World War I. Even though many serious infectious diseases have been brought under control, the last two decades of the twentieth century saw the rise of the deadly human immunodeficiency virus (HIV) both in the developed world and among developing nations.
Progress in disease control has been accompanied by disaster since exploration and travel began to come into prominence in the sixteenth century. The imperial expansion of Europe into the tropical regions, particularly Africa, brought Europeans into contact with diseases for which they had not developed immunity, and the conquerors of the New World carried with them a host of new diseases that devastated indigenous populations. The development of global trade and virtually unlimited personal mobility continued to encourage the spread of disease from continent to continent.
A profile of modern disease and mortality discloses differing patterns in developing and developed nations. In the less developed nations, infant mortality rates are high, life expectancy is low, and complications of pregnancy constitute the primary cause of death among women of childbearing age. In the more developed countries, where most of the infectious diseases have been brought under control and circulatory diseases take a greater toll of lives, mental health-related concerns are among the primary reasons people seek medical assistance.
A complicating factor in modern disease patterns is the “health transition” taking place in less developed countries that are undergoing rapid socioeconomic growth. These nations continue to be ravaged by tropical diseases and diseases associated with extreme poverty, yet they are also being assaulted by the diseases of the developed world.
The Declaration of Alma-Ata marked a milestone in a dialogue on human health that dates back to classical antiquity. Among the ancient Greeks, the dialogue was carried on between the proponents of Hygeia (from whose name the word “hygiene” is taken) and Asclepius (from whose name the word “scalpel” is taken). Hygeia personified the ideal, “a sound mind in a sound body.” Asclepius was a healer who turned to surgery and medicinal herbs to cure the ills of his patients. During the 1970’s and 1980’s, this dialogue was cast in terms of “horizontal” and “vertical” approaches to public health. The modern parallels to Hygeia and Asclepius, although not perfect, reflect similar principles.
The horizontal approach to public health addresses disease origins rather than intervention in disease mechanisms. Holistic in its orientation, it uses a wide variety of preventive strategies. The horizontal approach regards economic development and prosperity as the bases of soundness in all fields affecting public health—medical, ecological, sociological, and political. Accordingly, adequate diet and sanitation are key elements of its preventive regimen. A well-developed infrastructure, the product of economic development, is regarded as essential to both of these elements.
The vertical approach utilizes direct interventions on specific targets: Drugs, vaccines, and insecticides are applied locally to problem areas. The discovery and application of penicillin and the development of the polio vaccine are two examples of this approach from the twentieth century.
The horizontal approach has been supported conceptually by influential writings and historical developments. In his famous text An Essay on the Principle of Population, As It Affects the Future Improvement of Society (1798),
Furthermore, failures and mixed successes of some large-scale vertical campaigns led many to believe that they could not be as effective as the horizontal approach. Among the failures were the Rockefeller Foundation’s
Another factor supporting the horizontal approach was the rising cost of health care, especially hospital-based treatment. This problem developed first in the United States, where advances in medical technology made the best health care in the world available. It was available, however, to fewer and fewer people because health care costs were rising dramatically. Because the American system was looked to as a model, medical costs gradually began to rise in less developed countries as well.
A joint report in 1975 by WHO and the United Nations Children’s Fund (UNICEF)
These were the issues in the foreground and background as the custodians of public health gathered in 1978 at Alma-Ata in Kazakhstan. Under the leadership of Halfdan Theodor Mahler, director-general of WHO, the International Conference on Primary Health Care, sponsored by WHO and UNICEF, faced these issues boldly. In adopting the Declaration of Alma-Ata, the conference defined health in a revolutionary way and prescribed radical means to attain it.
According to the declaration, “Health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity”; it is a “fundamental human right.” The declaration described existing inequalities in health care, both between the developing and developed nations and within nations, as unacceptable and of common concern to all countries. Within a framework favoring horizontal approaches, it put primary health care forward as the most essential element of national health care programs. Calling on all countries to cooperate toward a common goal, the conference noted that a more effective use of the world’s resources could be achieved if military spending could be reduced through genuine policies of independence, peace, and disarmament. Working under these criteria and conditions, the conference established the year 2000 as a target date by which an acceptable level of health could be attained for all the people of the world.
The Declaration of Alma-Ata was controversial from its inception. Its definition of health, its observations on the means of attaining health, and its timetable were all subject to criticism. As for the target date of the year 2000, it soon became apparent that the declaration’s goal was unattainable. Even in 1978, World Bank president Robert McNamara noted in his annual report that optimistic projections of growth in developing countries would leave six hundred million people in absolute poverty by the end of the century. “Absolute poverty,” wrote McNamara, “is a condition of life so characterized by malnutrition, illiteracy, disease, high infant mortality and low life expectancy as to be below any reasonable definition of human decency.” McNamara’s statement reflected the prevailing emphasis of the horizontal approach toward health care. Among the more interesting developments following the Alma-Ata conference were the gradual rehabilitation of vertical interventions and the move toward reconciliation between the two camps.
UNICEF opened a gap between itself and WHO in 1983 by declaring a “children’s revolution” and recommending that, in addition to standard horizontal measures to eradicate diseases afflicting children, new scientific and technological breakthroughs be employed. These included oral rehydration therapy for diarrheal diseases and universal child immunization. Among the advantages cited for these vertical interventions were economy and efficiency. Furthermore, large-scale inoculation campaigns had proved their effectiveness in controlling such childhood killers as polio, measles, and whooping cough. Ironically, these diseases began cropping up in isolated pockets of the world during the late 1980’s and early 1990’s. It seems that overconfidence about the prospects for contracting the illnesses had led to lack of participation in vaccination programs.
Jonas Salk, developer of the first polio vaccine, and Robert McNamara met in 1983 to discuss the underutilization of immunization programs and to find ways to encourage WHO to join in the effort. Meetings to redefine health strategies were held at the Rockefeller Foundation’s Bellagio conference center in Italy in 1984, in Colombia in 1986, and in France in 1988. At the 1988 meeting, a “diagonal” approach, using both horizontal and vertical approaches, was proposed and generally well accepted. Meanwhile, evidence began to show that even poorer countries could achieve low rates of infant mortality and increased life expectancies through strategies based on political will, universal education, equitable distribution of health care facilities, and adequate caloric intake.
Although the goal of “health for all by the year 2000” was not met, many countries saw declines in infant mortality and improvements in overall health standards that were expected to continue. Another encouraging sign was the projected leveling off and eventual decline of world population. In addition, by the early twenty-first century many Asian countries achieved a level of food stability that removed perhaps as many as a billion people from the ranks of abject poverty as globalization prompted widespread economic growth and increased standards of living.
In the developed nations, many individuals looked to alternative lifestyles and alternative health systems to achieve more satisfactory levels of personal health. In particular, techniques from the traditional medical systems of China and India attracted the attention of both private citizens and health professionals. Meanwhile, access to health care became a major political issue in the United States, where calls for health care insurance reform and national medical insurance became prominent enough to affect election politics.
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Cartwright, Frederick F., and Michael Biddiss. Disease and History. 2d ed. Stroud, Gloucestershire, England: Sutton, 2000. Does not attempt to be encyclopedic in its breadth of coverage but seeks to reveal the complexity of the mechanisms responsible for widespread disease as well as the impacts of disease on society and on history. -
Chopra, Deepak. Perfect Health: The Complete Mind/Body Guide. Rev. ed. New York: Three Rivers Press, 2000. Chopra, an Indian trained in Western medicine, brings out the principles of the ancient Ayurvedic system of India. Not only examines fundamental theoretical principles but also prescribes daily and seasonal health routines based on psychophysiological types. -
Dubos, Rene J. Mirage of Health. New York: Doubleday, 1959. Offers a thoughtful counterpoint to the Declaration of Alma-Ata, arguing that health is an unattainable ideal, although one worth striving for. Thesis is supported with historical examples and philosophical reasoning in a humanistic framework. -
McKeown, Thomas. The Modern Rise of Population. New York: Academic Press, 1976. Volume released just prior to the Alma-Ata conference describes the pressures of population on the global society and lends support to the proponents of horizontal approaches to health care. This work is widely regarded as significant in its impact on the thinking of health professionals in the late 1970’s. -
Shorter, Edward. The Health Century. New York: Doubleday, 1987. Companion volume to a Public Broadcasting Service documentary details the history of vertical health interventions in the twentieth century. Provides insights into the business and the inside politics of the pharmaceutical industry. -
Thomas, Caroline, and Martin Weber. “The Politics of Global Health Governance: Whatever Happened to ’Health for All by the Year 2000’?” Global Governance 10, no. 2 (2004): 187-205. Scholarly work on health care policy around the world includes discussion of the impacts of the Declaration of Alma-Ata.
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