Prof Bart Criel, the initiator of the symposium, rightly pointed out that the Alma-Ata Declaration is a simple, 3-page document about the unfulfilled right to health and the widening of health inequities, and that it takes a clear stance on how the lack of access to health is morally, socially and politically unacceptable. 40 years after this declaration we find that half the world’s population cannot even obtain essential health services, while year after year 100 million are pushed into extreme poverty due to out-of-pocket healthcare spending, according to a 2017 report by the World Bank and WHO.

In trying to understand why so little has changed, we want to point out a ‘clear and present paradox’ that hovered over the discussions October 23^rd at the ITM – but extends much further than that.

When opening the one-day event, our ITM director brought forward that it should not be forgotten that the first and foremost responsibility of medical doctors is to take care of their patients. The last remark in the panel that brought the day to a close was about how family doctors also need to think about their own wellbeing, given this difficult task. And both were right: patients need healing and relief, and doctors need well-being as much as anyone else. But these messages also highlighted, perhaps unintentionally, the paradox that hinders progress in primary health care (PHC). The crucial issue was – and is – of course what should change to make sure that in 2058 (and hopefully much earlier) more convincing results on achieving ‘health for all’ can be shown.

Overall, the day was filled with in-depth contributions from the field, and proposals on how to renew and take forward PHC. Yet in some of the break-out groups, and in the concluding panel discussion, the paradox was very visible: while health is about so much more than health care, many of us seem to be stuck within healthcare boundaries. It is obvious that improved health requires engineers, law-makers, social activists and many more – including health professionals.

But with whom in the driver’s seat? When it comes to curing patients, (most) health professionals focus on illness and disease rather than on health. Which is good for the excited and enthusiastic social activist hit by a stroke. Should that lead to Kelsey Lucyk’s remark, when referring to Canada’s struggle with social determinants of health: “health has to add its voice, but in a respectful way, and also know when to get out of the way”? Richard Smith goes further when he expresses his concern about the ‘hegemony of the health people’: he is afraid that the “health people will always dominate with their computers, statistics, journals, theories, knowledge, and inability to think beyond the biomedical model and take over”. Perhaps we, the ‘health people’, should raise to the challenge. There are good arguments in what is brought forward by Lucyk and Smith. Both beg the question of a clear division of tasks within the broader health community.

We know that for developing and implementing health policies, health professionals are required. Health issues continuously compete for legitimacy and resources in the policy process, and this ‘agenda setting’ for Global Health has inspired much research. And although the role of many other disciplines is clear, it is never denied that ‘health people’ also have a role to play, and an important one. Within the health workforce there is slow but undeniable progress in recognizing the importance of a multidisciplinary workforce, acknowledging the huge contribution of informal carers/volunteers/social workers/people themselves in PHC, as was the topic of one of the break-out sessions. We may carry that division of mutually recognized tasks further, in order to prevent misunderstanding and improve effectiveness of the role of the ‘health people’ in PHC.

Tackling the infamous ‘medical-doctor perspective’ is important, and can be helped by improving a clear and outspoken relation of interdependency between the different disciplines in our own institution. We may want to show at ITM that it is self-evident that better health for all is built on the interdependency of first-rate biomedical knowledge and first-rate  knowledge of socio-economic-anthropological foundations of public health systems, policy-making and governance. That  may increase the relevance of the voice of ‘health people’ in the PHC debate – without claiming it for ourselves.

It might also help prevent conceptual confusion that can paralyze progress in formulating simple action points – as happened in another outbreak group. There, buzz-words such as sustainability and resilience^, seemed problematic, which could have been solved by including other disciplines.  The time won could have been used to discuss the other elephant in the room, the need for a ‘new economic order’, so central in the Alma-Ata declaration, perhaps echoed by the ‘doughnut framework’ of today’s world.

We have a dream, which we hope you share: before our next Alma-Ata commemoration all of us will have read sections I, II, III, IV, V, VII-1, VII-4, VII-5, VIII and X of the famous 1978 declaration. That should help….we  would, for example, hear no more plea from a closing panel to protect the ‘white privilege’ of western medical doctors to roam about the world to participate in the global health debate. Who knows, we might then already have found more equal ways to exchange knowledge and experience in the world – in order to provide equity and health for all.

#AidToo is a sub-section of the #MeToo movement which definitely needs no introduction, as the ripples it has caused continue to be felt all around the world. The growing activism and campaign to end sexual abuse has been well received, and the issue has been much debated across both virtual and the more traditional media platforms. Yet one question remains, why is this type of abuse structurally embedded in society and why it is so hard to tackle? This is of course a much more difficult and less popular subject matter. The truth is that the ‘root causes’ of sexual abuse and exploitation go a lot deeper than the glossy Hollywood magazines which were so useful to amplifying the voices of  #MeToo campaigners, would have you believe. In fact, Tarana Burke, the founder of the #MeToo movement, in calling for action, said “Sexual violence knows no race, class, or gender, but the response to it does.”

As previously alluded to, the session in Geneva tried to address the issue of sexual abuse and exploitation specifically within the “aid industry”. Since the story about sex-parties in Haiti broke, there has been an avalanche of similar stories throughout the “aid world,” with NGOs, UN bodies and peacekeepers all being implicated. The resulting public outrage has ensured that the issue is now firmly on the agenda, and these days, almost all aid industry CEOs speak of regaining trust.

The session was held under Chatham House rules which proved to be useful because after an initially slow start, people started opening up. At first there was a tendency to meekly accept blame and defend one’s agency efforts at making improvements, however, this soon gave way to people sharing sometimes bitter testimonies about how things at the very top in important agencies are not changing and how more senior staff manage to dodge their responsibilities. In the hands of the excellent facilitator we soon agreed on tasks that should be taken on by the ‘Aid Industry: there is a need to revaluate their response to allegations of abuse by their staff; to operationalise a common culture of integrity throughout what is in fact a very heterogenous sector; and to create survivor-centred response mechanisms.

Thus far, people seemed fairly comfortable sharing their opinions and experiences, yet at some  point we seemed to have got stuck at debating only how to end the abuse – whereas preventing it was not in sight. It was when the last presenter firmly brought the root causes back to centre that things became more complex. The discussion gradually veered from strictly ‘gender’ towards racial, class, and ethnic aspects of the issue. In other words, intersectionality entered, and immediately illuminated the elephant in the room: power.

We were quickly chased out of our comfort zone, where we all shared disgust for the ‘bad behaviour of some males’, and had to face questions about the asymmetry of power. Talking about the abuse of power proved a lot more difficult than agreeing about the horror of abusing women. We proved Tarana Burke right: the response to sexual violence includes race, class and gender…and the distribution of power.

There was some discussion on ways of moving forward that require a complete paradigm shift in the power balance and the current way of working of the aid industry. For instance, shouldn’t the people who need help be put in charge, also of the funds available? And why shouldn’t they be held accountable – not by ‘our’ standards per se, but a set of standards which respects the people who we are talking about more?

It is not helpful when (opinion) leaders of the aid industry throw their arms in the air and declare helplessly that it is all very difficult, because anyway in those weird countries, men treat their women like commodities… #TheyToo! The behaviour of individual men does not give outsiders the right to make overall judgments that are – even worse – painful illustrations of the very power imbalance that leads to abuse.

To at least prevent this, it may be more helpful for the aid industry to strengthen the effort to understand how local values are also trampled by warfare and extremism, and how each culture has systems in place which protect against abuse and violence. Holding people accountable according to those culture-specific systems, makes perhaps more sense than only using the abstract ‘rights-based’ approach – that sometimes seems a cover for a lack of interest for the local truth. That may the beginning of some deep introspection into how the industry may unwittingly perpetuate the conditions that allow such abuse to take place, as well as a reflection about how to promote wider societal and structural transformations in behaviour, attitudes and institutional priorities to produce lasting change.

We did not find the final solution of course, but the debate was instructive and positive. And we noted that there may be truth in a quote once used, ironically, by a man who lost his position in the #MeToo slipstream. Kevin Spacey, playing president Frank Underwood in ‘House of Cards’: “A great man once said, everything is about sex. Except sex. Sex is about power.”

Is this reaction itself another chapter in the series on ‘poverty porn’ that started almost four decades ago? True, not much has changed in the parallax world of international emergency aid. It is parallax because it has not changed its outlook on a world that changes all the time. The same type of advertisements keep being used, not only Oxfam but also Save the Children joins the ranks of NGOs with apologizing chiefs, while the modus operandi of sending ‘expatriate specialists’ to do what local people apparently are not deemed capable of, keeps throwing up colonial connotations of the white man’s burden.

Whether or not the critique is an example of selective morality, the fact is that the humanitarian world needs to change fast if it wants to remain part of the solution, and not cause more problems. The humanitarian system is broken for many reasons, and repairs are suggested. Prof Spiegel recommends among other things, integrating the people whose lives are affected, in aid delivery and the rebuilding national health systems, (by addressing the humanitarian–development nexus), as well as redesigning leadership and coordination mechanisms. He also advises making interventions efficient, effective, and sustainable. We tried to find evidence for effective interventions, but found it difficult to achieve our goal, and one of the reasons was that we could hardly find the local voice in the extensive literature review we did on coordination and health systems strengthening in fragile settings.

Local voices are the ones who should in the end legitimize the efforts being made by NGOs and all other stakeholders in the relief sector, but they seem to be among those who are ‘expulsed’, as Saskia Sassen formulates it. “Imagine, if you will, those people that reside at the edge of a system (not necessarily a geographical edge). Exclusion would be the prevention of people outside of that system entering it. Expulsion, however, is the act of those already within the system being ejected from it, and finding themselves on the other side of the line.” That is what is going on in these settings of inequality: refugees are not seen as equals, and are denied the right to be in charge. People are expulsed – even from their own agency. Sexual abuse is a symptom: we know that sexual abuse is about power more than it is about sex.

Bottom line for me in this unsavory Oxfam story: NGOs need to stop being on the ‘expulsing’ side of the line. Serving refugees whose identity, dignity and agency is respected should be done by handing over control to them. It is no longer acceptable to put expatriates in positions where they cannot be expected to deal with the obscene inequality in power. Include migrants and refugees in the design, implementation, management and accounting of relief work. Excuses of capability and corruption do not fly anymore – and have probably never done. The ‘humanitarian world’ needs to wake up from its parallel reality, its slumber of neutral, impartial and independent “splendid isolation” – wake up and adapt to the realities of different value systems, political realities, growing remittance flows and real people.