Halfdan Mahler: Quien redefinió la salud pública. Debabar Banerji a su amigo / Halfdan Mahler: who redefined public health
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| Gato virtual. ArtE en Colonia de Sacramento, Uruguay. Mayo 2017, Foto del editor. |
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Agradezco al Profesor Banerji quien permitió publicar en el blog en su nombre este manuscrito, aún inédito, de su declaración en honor de Halfdan Mahler.
Mahler fue director general de la OMS desde 1973 hasta 1988.
El lideró el proceso que condujo a la icónica Conferencia Mundial de Alma Ata (Kazajastán, URSS, 1978) y fue en parte responsable de las consecuencias que se desencadenaron de esta.
El tomó contacto con la realidad de la atención sanitaria y la importancia de su dimensión comunitaria, cuando estuvo en India para trabajar en la campaña contra la Tuberculosis que lideraba Debabar Banerji. Banerji fue un comprometido compañero al todas las luchas que tuvieron que enfrentar en India, mas tarde en la OMS y mas allá. Fue responsable de algunos de los documentos preparatorios de la Conferencia, los que escribió desde su experiencia en India y que terminaron siendo parte de la tan célebre declaración.
El texto completo de Banerji está en la sección en Ingles de esta nota. Sin embargo se han traducido algunos fragmentos aquí.
Miguel Pizzanelli
Mas: http://estancambiandolostiempos.blogspot.com.uy/2016/12/halfdan-mahler-ha-sido-saboteada-la.html
HALFDAN MAHLER: QUIÉN REDEFINIÓ LA SALUD PUBLICA.
(solamente fragmentos seleccionados)
El concepto de Atención Primaria de la Salud (APS) marca una línea divisoria en la Salud Pública como disciplina, lo que Mahler llamó una revolución. Subordinaba las prácticas tecnológicas y administrativas a las necesidades del pueblo. Proporcionó una hoja de ruta para desarrollar servicios de salud en diferentes países. Incluso las formas más rudimentarias de remedios caseros o la intervención del huesero de la aldea, podían formar el punto de partida para el desarrollo de la APS. Mahler se había propuesto audazmente afrontar todo lo que implicaba la implementación de la APS, que exigía una forma cualitativamente diferente de competencia en la práctica y la investigación en salud pública y asimismo afrontar la inevitable caída política que le podía provocar una tarea tan audaz.
El viaje a esta "revolución" comenzó hace 27 años, en la India. Mahler comenzó su trabajo en salud pública en la India en 1951. Se encontró con el estudio de Madras que demostró que el tratamiento domiciliario de la tuberculosis era tan eficaz como el tratamiento en los hospitales de esa época. Sin embargo, llevó al joven médico mucho más tiempo para deshacerse del dogma más profundamente arraigado respecto a la vacunación masiva con BCG, con la que comenzó su trabajo en tuberculosis. También le tomó tiempo distanciarse de la poderosa iniciativa de la industria para explotar el mercado indio y vender máquinas para realizar radiografías en forma masiva.
Sucedió que yo también quería subordinar la tecnología médica a los intereses de la gente de mi país, y no al revés. Esto me llevó muy cerca de Mahler, cuando me uní a Instituto Nacional de la Tuberculosis (INT) en 1959. Trabajamos juntos con entusiasmo para alcanzar el mandato dado a INT. Este compromiso común sentó las bases de nuestra profunda amistad de por vida. Conversaríamos alegremente durante horas sobre diversos aspectos de nuestras tareas, a veces discutiendo vigorosamente, para finalmente terminar con un feliz consenso como desenlace. Recientemente, cuando le envié el borrador de un capítulo en mi autobiografía sobre el INT, recibí una respuesta cariñosa de mi "Dada":
Querido amigo, querido Kuli (hombre trabajador)
Mi cálido agradecimiento por tu correo electrónico de 30.08.07. ¡Espero que te des cuenta de los increíbles dones con los que has sido regalado por la naturaleza y me gustaría advertirte sobre lo increíblemente bien que haz desarrollado estos talentos!
Aún tienes muchos años para bendecir a tus alumnos y me siento orgulloso de ser uno de ellos con tu percepción intelectual, social y política. Muchas gracias y saludos.
Halfdan.
Mahler siguió utilizando estas posiciones en la OMS (se refiere a su posición como director general por res períodos consecutivos en la OMS) para hacer frente a los poderosos intereses comerciales al abordar causas tales como la fijación de precios de medicamentos esenciales y la enfrentar a las multinacionales por la antiética promoción de fórmulas industriales de alimentos infantiles, en países pobres.
En su intervención en una conferencia internacional de educadores en salud, observó: "Espero sinceramente que esta Conferencia redacte el obituario a ese tipo de educación sanitaria que se ocupa de decirle a la gente cómo actuar en lugar de considerar las fuerzas sociales que los llevan a actuar como lo hacen”. Mostrando su frustración por la inflexibilidad en la educación médica y las prácticas en los países occidentales, fustigó a la "mafia médica". Esto provocó protestas inmediatas de estos países y Mahler se vio obligado a retirar sus comentarios. Posiblemente notando el clima político cambiante, no buscó su cuarto mandato.
Hubo cambios exponenciales en las ecuaciones de poder entre y dentro de los países del mundo desde principios de los años ochenta. La respuesta de los países ricos a la propuesta de la declaración de autosuficiencia y autodeterminación de los pobres del mundo en Alma Ata fueron rápidas y agudas. Ellos mostraron su falta de comprensión sobre la Declaración de Alma Ata al afirmar que la mayoría de los países en desarrollo eran demasiado pobres para llevar a cabo lo que ellos llamaron "atención primaria de salud integral". La alternativa sugerida por ellos en 1979 se llamó el enfoque de la Atención Primaria Selectiva de Salud (APSS), con prácticamente ningún aval de evidencia científica. Se hizo un esfuerzo activo para eliminar las ideas generadas por la Declaración para dar cabida a una agenda de salud claramente no científica y orientada al mercado para aplicar en los países pobres. El médico social Vicente Navarro calificó este hecho como "fascismo intelectual". El enfoque de "arriba a abajo" de la salud pública volvió a aparecer, siendo las personas nuevamente receptoras desafortunadas de programas prefabricados, impulsados por un mercado, tecnocéntrico, científicamente insostenibles, impuestos por agencias internacionales, con el apoyo total de muchos de los países ricos . Estos movilizaron enormes recursos de organizaciones como la OMS, el UNICEF y el Banco Mundial para promover su agenda de APSS.
En un intento desesperado de recuperar cierta credibilidad, la OMS logró interesar a algunos de los principales economistas del mundo a unirse a la Comisión de Macroeconomía y Salud (CMH) para estudiar las implicaciones macroeconómicas de la inversión en servicios de salud. Como era de esperar, el informe de la comisión fue ahistórico, políticamente motivado y ateórico. Adoptó un enfoque selectivo para ajustarse a una ideología preconcebida e ignoró deliberadamente desarrollos tan importantes en los servicios de salud como la Declaración de Alma Ata. La OMS se había alejado de sus días Mahler.
Una cruel ironía es que la breve declaración de la OMS sobre la muerte de Halfdan Mahler refleja la confusión y la amnesia del actual “staff” de la OMS. Se han olvidado que la Conferencia de Alma Ata fue sobre "Atención Primaria de Salud", y no sobre "Atención Primaria". El descuido de los pocos periodistas que comentaron la muerte de Mahler puede ser perdonado. La BBC también puede ser perdonada porque se mantuvieron ocupados derramando lágrimas para los numerosos miembros de la industria del entretenimiento que hicieron su salida en esta época del año. En la India, hubo un silencio ensordecedor. Los ministros de salud y los secretarios de salud, que controlan los servicios de salud de la India, tal vez ni siquiera conocen a Halfdan Mahler. Mahler ¿Quién? A Halfdan no le habría sorprendido ni le habría importado. Tampoco a mí.
Debabar Banerji
ENG
I appreciate Professor Banerji who allowed to post on his behalf this yet unpublished manuscript of his statement in honour of Halfdan Mahler.
Mahler was General Director of WHO from 1973 to 1988.
He led the process that resulted in the iconic World Conference of Almaty (Kazakhstan, USSR, 1978) and its consequences. He met the reality of health care and the importance of its community dimension, when he went to India to collaborate in the campaign against Tuberculosis headed by Debabar Banerji. Banerji was a committed mate in all this fights in India and later in the WHO and beyond.
More details follow this link: http://estancambiandolostiempos.blogspot.com.uy/2016/12/halfdan-mahler-ha-sido-saboteada-la.html
Miguel Pizzanelli
On mahler
December 28 2016
HALFDAN MAHLER: WHO REDEFINED PUBLIC HEALTH
Debabar Banerji
Professor Emeritus
Centre of Social Medicine and Community Heath
Jawaharlal Nehru University
New Delhi
Former WHO director-general Halfdan Mahler, who passed away on December 14, 2016, was perhaps the most outstanding public health worker of his time. The most important achievement of his life was easily the Alma Ata Declaration. He was the driving force behind the 1978 International Conference on Primary Health Care (PHC) at Alma Ata in the USSR in which 120 countries declared that PHC was the key to attaining the target of health for all by the year 2000.
The concept of PHC marks a watershed in the discipline of public health—Mahler called it a revolution. It subordinated technological and administrative practices to the needs of the people. It provided a road map for developing health service in different countries. Even the most rudimentary forms of home remedies or use of a village bone-setter could form the starting point of development of PHC. Mahler had boldly set out to face the implications of implementing PHC which called for a qualitatively different form of competence in public health practice and research, and the inevitable political fallout of undertaking such an audacious task.
The journey to this “revolution” began 27 years ago—in India. Mahler started his public health work in India in 1951. He came upon the Madras Study that proved that domiciliary treatment of tuberculosis is as efficacious as the age-old sanatorium treatment. It, however, took the young doctor much longer to get rid of the more deeply embedded dogma of the mass vaccination with BCG with which he started his tuberculosis work. He also took time to distance himself from the powerful drive by the industry to exploit the Indian market for selling machines for mass radiography.
Mahler found support from the Indian establishment. P.V. Benjamin, the Tuberculosis Advisor to the government, Rakumari Amrit Kaur, the then Union Health Minister and, above all, Prime Minister Jawaharlal Nehru were deeply impressed by his missionary zeal to serve the un-served and the under-served. He was also noticed by his superiors in WHO, like C. Mani of the Regional Office in New Delhi and Johannes Holm, Tuberculosis Chief in the Headquarters.
This inspired him to conceptualise an interdisciplinary research institution – the National Tuberculosis Institute, Bangalore (NTI) -- where international experts and their national counterparts will work for dealing with tuberculosis as a public health problem in India “in a mutually respectful relationship”. In 1959, Mahler used his formidable persuasive power to get acceptance of his proposal by WHO, UNICEF and the government of India.
It so happened that I too wanted to subordinate medical technology to the interests of the people of the country, rather than the other way round. This brought me very close to Mahler, when I joined NTI in 1959. We worked together most enthusiastically to attain the mandate given to NTI. This common commitment laid the foundation of our deep lifelong friendship. We would joyfully talk for hours together on various aspects of our tasks, sometimes differing vigorously only to end evolving a happy rational consensus. Recently, when I sent him a draft of a chapter in my autobiography on NTI, I got an affectionate reply from my “Dada”:
Dear friend, dear Kuli.
My warm thanks for your e-mail of 30.08.07. I hope you realize how incredibly
gifted you are from nature’s hand and I would like to tell you how incredibly well you have realized your talents!
You still have many years to bless your pupils-and I am proud to be one of
these-with your intellectual, social and political insights.
Warmest thanks and regards.
Halfdan.
Giving a new direction for public health research by introducing concepts and data in areas such as social dimensions of epidemiology of tuberculosis, outlining an integrated approach to diagnosis and treatment, giving a social orientation of use of technology, drastically refining the definition of a case of tuberculosis and, most importantly, using such research tools as operational research and systems analysis to devise optimal use of available resource, led to the formulation of India’s National Tuberculosis Programme (NTP) which is nationally applicable, socially acceptable and epidemiologically effective.
Convincing scientific evidence in the formulation of the NTP was warmly accepted by the government of India and elaborate efforts were started to implement the mechanisms of the recommendations. Key organisations such as the Fourth WHO Expert Committee on Tuberculosis (1964) and the International Union Against Tuberculosis also warmly welcomed the scientific bases of NTP. Even more importantly, as has been publicly mentioned by Mahler himself, this research philosophy of NTI has been consistently used in the conceptualisation and formulation of PHC.
Mahler’s work in India led WHO to assign him to key positions at the Headquarters. In recognition of his achievements, the World Health Assembly elected him to the top post on three consecutive terms (1973-88).
Mahler continued to use these positions in WHO to confront powerful commercial interests by taking up such causes as pricing of essential drugs and reining in multinational industries against unethical promotion of baby food formulae in poor countries. Speaking at an international conference of health educators, he observed: “I sincerely hope that this Conference will write an obituary to that type of health education which was concerned with telling people how to act and that instead it will emphasise taking due consideration of the social forces that bring them to act as they do”. Showing his frustration at inflexibilities in medical education and practices in Western countries, he castigated the “Medical Mafia.” This evoked immediate protest from these countries and Mahler was compelled to withdraw his remarks. Possibly noting the changing political climate, he did not seek a fourth term.
There were exponential changes in the power equations between and within the countries of the world from the early 1980s. The responses of the rich countries to the proposed declaration of self-reliance and self-determination by the poor people of the world at Alma Ata were swift and sharp. They showed their lack of understanding of the Alma Ata Declaration by contending that most of the developing countries were too poor to undertake what they called “comprehensive primary health care”. The alternative suggested by them in 1979 was called the approach of Selective Primary Health Care (SPHC), with virtually no scientific evidence. An active effort was made to wash away the ideas generated by the Declaration to make space for patently unscientific, market-driven agenda for health for the poor countries. Social physician Vicente Navarro called this “intellectual fascism”. The “above down” approach to public health was brought back, with people once again becoming hapless recipients of pre-fabricated, market-driven, techno-centric and scientifically untenable programmes imposed by international agencies, with full support from many of the rich countries. The rich countries mobilised enormous resources of organisations such as the WHO, UNICEF and the World Bank to promote their agenda of SPHC.
Substituting scientific reasoning and well-researched conclusions that Mahler had instituted with brute political power, the syndicate of rich countries, international health agencies and big NGOs launched a virtual torrent of what they called International Initiatives on the poor countries. One of the most astonishing features of taking such global initiatives was that WHO and other international organizations and scholars of public health schools in Western countries missed the very obvious fact of sharp differences among the poor countries of this world. Despite massive investment into these programmes running into billions of US dollars, they have fallen far short of their targets. In the bargain, they inflicted further damage to the already battered general health services of the Member States, particularly those of the very poor countries.
In a desperate bid to regain some credibility, WHO managed to interest some of the top economists of the world to join its Commission on Macroeconomics and Health (CMH) to study macroeconomic implications of investment in health services. As can be expected, the report of the commission was ahistorical, politically motivated and atheoretical. It adopted a selective approach to conform to a preconceived ideology and pointedly ignored such major developments in the health services as the Alma Ata Declaration. WHO had moved away from its Mahler days. Its latest effort is to set up the Commission on Social Determinants of Health (CSDH) “to improve health and narrow health inequalities through action on social determinants”. After what happened to the WHO-UNICEF sponsored Alma Ata Declaration, such expectations look patently untenable, if not downright hypocritical. Inadequacies of both commissions reflect a crisis in the practice of international health at WHO, stemming from a combination of unsatisfactory administrative practices and lack of technical competence to provide insights into the problems afflicting the neediest countries. Often the WHO has ended up distorting the already rudimentary health systems of the poor countries, by pressuring them into accepting health policies, plans, and programmes that lack sound scientific bases.
A cruel irony is that the short statement by WHO on the death of Halfdan Mahler reflects the confusion and amnesia of the present staff of WHO. They have forgotten that Alma Ata Conference was about “Primary Health Care”, and not about “Primary Care”. Carelessness of the very few journalists who commented on Mahler’s death can be forgiven. The BBC can also be forgiven because they were kept busy shedding tears for the numerous members of the entertainment industry who made their exit at this time of the year. In India, there was deafening silence. The health ministers and the health secretaries at the Centre and in the states, who control the health service of India, may not even know Halfdan Mahler. Mahler? Who? Halfdan would not have been surprised or cared. Nor do I.
Debabar Banerji
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