Building a comprehensive public health movement: learning from HIV/AIDS mobilisations
Abstract
In 1978, world leaders assembled in Almaty (formerly Alma-Ata) in Kazakhstan to sign an international declaration highlighting the importance of primary healthcare services around the world. The result was a landmark document in the history of public health: the ‘Alma Ata Declaration’ -- an agreement of WHO member states to implement ‘health for all’ by the year 2000. While this landmark document set out a bold vision for the future, it was unfortunately followed by decades of disappointment. In the ensuing discussions, public health became divorced from community concerns and governments failed to react urgently to what was to become the greatest public health catastrophe of our time, the AIDS pandemic, and the resurgence of tuberculosis that has followed in its wake in many parts of the world.
Although the WHO and other international agencies, as well as domestic ones in the US and elsewhere, were resistant to responding to the epidemic, ordinary men and women in South Africa, Thailand, Brazil, the US and Europe did react, creating a community-based movement that forced a major shift in public health funding, health system infrastructure, and notions of accountability in public health. The HIV/AIDS mobilisations offer important lessons for the wider discussion over health today. As we expand the field of ‘global health’, we must recognize that the debates we construct and respond to are intimately tied to our power to define what is relevant and not, what is appropriate and not, what is sustainable and not, and what is worthy and not. The HIV activism movement has taught us about democratising this process, such that who makes these declarations is as important as the declarations themselves; we risk losing the power of this lesson if we attempt to return public health to an activity that is focused on elite economic theories devised in distant centres (however sensible they may seem rhetorically), rather than community-based programmes decided by patients. We must also abandon a rhetoric that is focused on only the most minimal care and most basic needs, which is devised to preserve current inequalities, and create both the language and systems to redistribute the power of decision-making from traditional public health decision-makers to patients.
Although the WHO and other international agencies, as well as domestic ones in the US and elsewhere, were resistant to responding to the epidemic, ordinary men and women in South Africa, Thailand, Brazil, the US and Europe did react, creating a community-based movement that forced a major shift in public health funding, health system infrastructure, and notions of accountability in public health. The HIV/AIDS mobilisations offer important lessons for the wider discussion over health today. As we expand the field of ‘global health’, we must recognize that the debates we construct and respond to are intimately tied to our power to define what is relevant and not, what is appropriate and not, what is sustainable and not, and what is worthy and not. The HIV activism movement has taught us about democratising this process, such that who makes these declarations is as important as the declarations themselves; we risk losing the power of this lesson if we attempt to return public health to an activity that is focused on elite economic theories devised in distant centres (however sensible they may seem rhetorically), rather than community-based programmes decided by patients. We must also abandon a rhetoric that is focused on only the most minimal care and most basic needs, which is devised to preserve current inequalities, and create both the language and systems to redistribute the power of decision-making from traditional public health decision-makers to patients.