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40 years Alma Ata: middle age or a mid-life crisis?

By Kristof Decoster
on July 3, 2018

As you probably know by now, this year the 40th anniversary of the Alma Ata declaration is being celebrated. The declaration committed the world to achieving Health for All via Primary Health Care (PHC), and this by 2000. That didn’t quite work out.

As a reminder, “The Primary Health Care principles affirm health as a human right based on equity and social justice, implemented through community engagement, health promotion, the appropriate use of resources, and intersectoral action based on a New International Economic Order with the vision of health for all by the year 2000”.

From a male point of view, 40 years is also more or less the official start of ‘middle age’. Some men even skip middle age altogether and go straight for a mid-life crisis : )

The middle age years are usually considered as the most productive years of one’s life, among others because you’re then still more or less healthy (or at least supposed to be so), and benefit from more experience and wisdom (as compared to the youngsters). I know, that’s the theory.

As for a mid-life crisis: I’m not an expert, but now over 45 years old myself, this weekend I came across one of the better descriptions of what a mid-life crisis might involve (in an interview with a 46-year old male musician in a national newspaper): “It’s about wanting back chaos in one’s life, instead of structure.

From that –  middle age/midlife crisis? –  angle, I’d like to reflect a bit more on the 40th Alma Ata anniversary. Is Alma Ata 2.0 about “updating” the original vision & declaration, translating it to a new era, building and capitalizing to a large extent on the experience and lessons learnt (including via some of the failures) in recent decades, or do we need to start from scratch, given the current times? Go for Tabula rasa?

I just raise the question here, I don’t have an answer to this. (One of the things you start realizing as a middle-aged man, is that you have few answers : ) )

The least you can say, though, is that the original Alma Ata vision has not really materialized. Not by 2000, and not by 2018 either. With a bit of imagination, it feels a bit like how quite a few men, when they get 40, begin to reflect on their journeys and lives so far and realize that many of their dreams have not been realized (or worse).

Against that backdrop (i.e. a rather sorry Alma Ata track record), it would appear that we need a better game plan, aka a “Theory of Change” for Alma Ata 2.0, to make sure that ‘This time will (indeed) be different’. The first game plan clearly sucked.

And no, the following paragraph from the draft declaration doesn’t fit the bill: “We commit to taking bold and tangible steps to address the health challenges of the 21st century. We hereby launch a global movement in pursuit of UHC and the SDGs, ensuring that primary health care is at the core of this movement.

The  draft declaration lists some of the current challenges in an Alma Ata 2.0 era, but deep analysis of how many of these are interlinked – as is done for example in Paul Mason’s book,  Postcapitalism: a guide to our future  –  is lacking. You would also expect an Alma Ata 2.0 exercise to map out different scenarios, one for example for PHC in a post-capitalist world, one for a world in which capitalism somehow manages to adapt & mutate once again (to a greener economy, and an economy where, in spite of further automation & robotization some sort of a functioning global social contract materializes by 2030 and beyond), one where we just muddle along, …

True, when talking about an amount of chaos in the world, the first Alma Ata declaration also saw the light in a time of turmoil. So you might say, what’s new?

Still, our times seem to point even more to the end of a long cycle, with among others, the implosion and moral bankruptcy of neoliberalism (at least in the minds of people, not yet in (enough) country & institutions’ policies), the political backlash this moral implosion causes (linked also to the unfortunately toxic issue of migration) in many countries, with even globalization itself now under threat in some corners (for example when it comes to trade rules), the rise of Big Tech and disruptive platform capitalism, ecological constraints which have become far more prominent and worrying compared to 40 years ago (and which even seem to warrant a new planetary health paradigm), the gender perspective (absent altogether in  the original Alma Ata declaration) & the global (and hopefully unstoppable) rise of women empowerment (even if it faces also a backlash), the financialization of the global economy in the decades since Alma Ata, hyper-commercialized global capitalism (even if many don’t find it very appealing), the fact that the developed/developing countries’ distinction increasingly feels irrelevant, etc. Last but not least,  with Trump et al, there’s even a certain danger that the multilateral order gets blown up altogether.

In short, maybe it’s not the end of an era, but it sure feels like one.

For now, the “New Global Economic Order” (NGEO) which the Geneva Global Health Hub deems vital (for Alma Ata 2.0 to materialize), in its consultation statement after a recent workshop – a new order based on solidarity, a human rights approach, combining a social foundation for all with an ecological ceiling, etc., remains a remote dream. True, many social movements are working hard towards such a NGEO, but they have their (nasty) counterparts as well (often in cahoots with the Kochs of this world), and certainly on bad days it feels like the latter have increasingly the upper hand. Instead of a New Global Economic Order, we seem to be heading for a different kind of (dis)order, step by step.

I’m sure it would involve a certain amount of speculation, but Alma Ata 2.0 should try to spell out what the world needs to do to avoid such a doom scenario. In a world of disorder and chaos, PHC and the like will almost certainly remain pipe dreams. I hate to say so, but economists (preferably of the Kate Raworth kind) should probably be on the front rows in Almaty.

Most 40-year old men, even the ones going through a mid-life crisis, don’t want total chaos.  Not being very resilient anymore, they can’t cope with it. They just want a bit of chaos and unpredictability back in their lives 🙂

Maybe the same is true for Alma Ata 2.0?  There’s not much wrong with the vision and core principles of Alma Ata, and no doubt if ‘Health for All’ & PHC are to be reached by 2030, we can build on many insights and lessons from the past. Still, in the current draft, I miss a bit of unpredictability, nonlinearity, anticipation of chaos/doom, tipping points, … In short, a bit of complexity (theory).

But then again, I’m a man in his forties.

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