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PUBLIC HEALTH THEN AND NOW

The
ORIGINS of Primary Health Care
and SELECTIVE Primary Health Care

| Marcos Cueto, PhD

I present a historical study of the DURING THE PAST FEW BACKGROUND AND spray guns and vaccinating
role played by the World Health Or- decades, the concept of primary CONTEXT syringes.2
health care has had a significant In a similar perspective, Carl
ganization and UNICEF in the emer-
influence on health workers in During the final decades of the Taylor, founder and chairman of
gence and diffusion of the concept of
many less-developed countries. Cold War (the late 1960s and the Department of International
primary health care during the late
However, there is little under- early 1970s) the US was em- Health at Johns Hopkins Univer-
1970s and early 1980s. I have ana- standing of the origins of the sity, edited a book that offered
broiled in a crisis of its own
lyzed these organizations political term. Even less is known of the world hegemonyit was in this Indian rural medicine as a gen-
context, their leaders, the method- transition to another version of political context that the concept eral model for poor countries.3
ologies and technologies associated primary health care, best known of primary health care emerged. Another influential work was by
with the primary health care per- as selective primary health care. By then, the so-called vertical Kenneth W. Newell, a WHO staff
spective, and the debates on the In this article, I trace these ori- health approach used in malaria member from 1967, who col-
meaning of primary health care. gins and the interaction be- eradication by US agencies and lected and examined the experi-
These debates led to the develop- tween 4 crucial factors for inter- the WHO since the late 1950s ences of medical auxiliaries in
ment of an alternative, more restricted national health programs: the were being criticized. New pro- developing countries. In Health
context in which they appeared, posals for health and develop- by the People, he argued that a
approach, known as selective primary
the actors (personal and institu- ment appeared, such as John strict health sectorial approach
health care. My study examined library
tional leaders), the targets that Bryants book Health and the De- is ineffective.4 In addition, the
and archival sources; I cite examples
were set, and the techniques veloping World (also published in 1974 Canadian Lalonde Report
from Latin America. proposed. I use contemporary (named after the minister of
Mexico in 1971), in which he
publications, archival informa- questioned the transplantation of health) deemphasized the impor-
tion, and a few interviews to lo- the hospital-based health care tance attributed to the quantity of
cate the beginnings of these system to developing countries medical institutions and proposed
concepts. I emphasize the role and the lack of emphasis on pre- 4 determinants of health: biology,
played by the World Health Or- vention. According to Bryant, health services, environment, and
ganization (WHO) and UNICEF Large numbers of the worlds lifestyles.5
in primary health care and se- people, perhaps more than half, Other studies, written from
lective primary health care. The have no access to health care at outside the public health commu-
examples are mainly drawn all, and for many of the rest, the nity, were also influential in chal-
from Latin America. The work care they receive does not an- lenging the assumption that
is complementary to recent swer the problems they have . . . health resulted from the transfer-
studies on the origin of primary the most serious health needs ence of technology or more doc-
health care.1 cannot be met by teams with tors and more services. The

1864 | Public Health Then and Now | Peer Reviewed | Cueto American Journal of Public Health | November 2004, Vol 94, No. 11
PUBLIC HEALTH THEN AND NOW

British historian Thomas Mc- office of the World Council of NEW ACTORS AND NEW
Keown argued that the overall Churches (and 50 WHO staff re- HEALTH INTERVENTIONS
health of the population was less ceived Contact ).9
related to medical advances than Another important inspiration New leaders and institutions
to standards of living and nutri- for primary health care was the embodied the new academic and
tion.6 More aggressively, Ivan Il- global popularity that the mas- political influences. Prominent
lichs Medical Nemesis contended sive expansion of rural medical among them was Halfdan T.
that medicine was not only irrele- services in Communist China ex- Mahler of Denmark. He was
vant but even detrimental, be- perienced, especially the bare- elected the WHOs director gen-
cause medical doctors expropri- foot doctors. This visibility co- eral in 1973 and was later re-
ated health from the public. This incided with Chinas entrance elected for 2 successive 5-year
book became a bestseller and into the United Nations (UN) terms, remaining at its head until
was translated into several lan- system (including the WHO). 1988. Mahlers background was
guages, including Spanish.7 The barefoot doctors, whose not related to malariology, the
Another important influence numbers increased dramatically discipline that dominated inter-
for primary health care came between the early 1960s national health during the
from the experience of mission- and the Cultural Revolution 1950s. His first international ac-
aries. The Christian Medical (19641976), were a diverse tivities were in tuberculosis and
Commission, a specialized organ- array of village health workers community work in less-devel-

Source. Prints and Photographs Collection, History of


ization of the World Council of who lived in the community oped countries. Between 1950

Medicine Division, National Library of Medicine,


Churches and the Lutheran they served, stressed rural rather and 1951, he directed a Red
World Federation, was created in than urban health care and pre- Cross antituberculosis campaign
the late 1960s by medical mis- ventive rather than curative in Ecuador and later spent sev-
sionaries working in developing services, and combined Western eral years (19511960) in India
countries.8 The new organization and traditional medicines.10 as the WHO officer at the Na-
emphasized the training of vil- Primary health care was also tional Tuberculosis Program. In
lage workers at the grassroots favored by a new political context 1962, he was appointed chief of
level, equipped with essential characterized by the emergence the Tuberculosis Unit at the
drugs and simple methods. In of decolonized African nations WHO headquarters.13 In Geneva,

Bethesda, Md.
1970, it created the journal Con- and the spread of national, anti- Mahler also directed the WHO
tact, which used the term pri- imperialist, and leftist movements Project on Systems Analysis, a
mary health care, probably for in many less-developed nations. program that implied improving
the first time. By the mid-1970s, These changes led to new pro- national capabilities in health Halfdan T. Mahler, director general of
French and Spanish versions of posals on development made by planning. the World Health Organization,
the journal appeared and its cir- some industrialized countries. More importantly, Mahler was 19731988.
culation reached 10 000. Modernization was no longer a charismatic figure with a mis-
It is worth noting that John seen as the replication of the sionary zeal. His father, a Baptist
Bryant and Carl Taylor were model of development followed preacher, helped shape his per-
members of the Christian Medical by the United States or Western sonality. Many years after his re-
Commission and that in 1974 col- Europe. For example, Prime Min- tirement from the WHO, he ex-
laboration between the commis- ister Lester B. Pearson of Canada plained that for him, social
sion and the WHO was formal- and Chancellor Willy Brandt of justice was a holy word.14 The
ized. In addition, in Newells West Germany chaired major strong impression he produced in
Health by the People, some of the commissions on international de- some people is well illustrated by
examples cited were Christian velopment emphasizing long-term a religious activist who met
Medical Commission programs socioeconomic changes instead of Mahler in the 1970s: I felt like a
while others were brought to the specific technical interventions.11 church mouse in front of an
attention of the WHO by commis- In a corollary decision, in 1974 archbishop.15
sion members. A close collabora- the UN General Assembly Mahler had excellent relations
tion between these organizations adopted a resolution on the Es- with older WHO officers. The
was also possible because the tablishment of a New Interna- Brazilian malariologist Marcolino
WHO headquarters in Geneva tional Economic Order to uplift Candau, the WHO director gen-
were situated close to the main less-developed countries.12 eral before Mahler, appointed the

November 2004, Vol 94, No. 11 | American Journal of Public Health Cueto | Peer Reviewed | Public Health Then and Now | 1865
PUBLIC HEALTH THEN AND NOW

From the late 1960s, there was an increase in WHO projects


related to the development of basic health services
(from 85 in 1965 to 156 in 1971). These projects were
the institutional predecessors of the primary health
World Health Assembly, Mahler
proposed the goal of Health for
All by the Year 2000. The slo-
gan became an integral part of
primary health care. According


to Mahler, this target required a
care programs that would later appear. radical change. In a moving
speech that he delivered at the
1976 assembly, he said that
Dane as an assistant director gen- tween 1965 and 1979, who had Many social evolutions and rev-
eral in 1970. Thanks to his close his own rich experience with olutions have taken place be-
relationship with the WHOs old community-based initiatives in cause the social structures were
guard, Mahler could ease the health and education. The agree- crumbling. There are signs that
transition experienced by this ment produced in 1975 a joint the scientific and technical struc-
agency under his command. WHOUNICEF report, Alterna- tures of public health are also
Some of these changes occurred tive Approaches to Meeting Basic crumbling.19 These ideas would
before Mahler assumed the post Health Needs in Developing Coun- be confirmed at a conference
of director general. From the late tries, that was widely discussed that took place in the Soviet
1960s, there was an increase in by these agencies. The term al- Union.
WHO projects related to the de- ternative underlined the short-
velopment of basic health serv- comings of traditional vertical ALMA-ATA
ices (from 85 in 1965 to 156 in programs concentrating on spe-
1971).16 These projects were in- cific diseases. In addition, the as- The landmark event for pri-
stitutional predecessors of the pri- sumption that the expansion of mary health care was the Inter-
mary health care programs that Western medical systems national Conference on Primary
would later appear. Another early would meet the needs of the Health Care that took place at
expression of change was the cre- common people was again highly Alma-Ata from September 6 to
ation in 1972 of a WHO Division criticized. According to the docu- 12, 1978. Alma-Ata was the
of Strengthening of Health Ser- ment, the principal causes of capital of the Soviet Republic of
vices. Newell, a strong academic morbidity in developing coun- Kazakhstan, located in the Asi-
and public health voice for pri- tries were malnutrition and vec- atic region of the Soviet Union.
mary health care, was appointed tor-borne, respiratory, and diar- According to one of its organiz-
director of this division (Newells rheal diseases, which were ers, the meeting would tran-
career with the WHO started in themselves the results of pov- scend the provenance of a
1967 as director of the Division erty, squalor and ignorance.18 group of health agencies and
of Research in Epidemiology and The report also examined suc- exert moral pressure for pri-
Communications Science). cessful primary health care expe- mary health care.20 A Russian
In 1973, the year of Mahlers riences in Bangladesh, China, co-organizer claimed that never
appointment as the WHO direc- Cuba, India, Niger, Nigeria, Tan- before [have] so many countries
tor general, the Executive Board zania, Venezuela, and Yugoslavia prepared so intensively for an
of WHO issued the report Orga- to identify the key factors in their international conference.21
nizational Study on Methods of success. The then-current tension
Promoting the Development of This report shaped WHO among communist countries
Basic Health Services.17 This re- ideas on primary health care. played an important role in the
port was the basis for a redefini- The 28th World Health Assem- selection of the site. The Chinese
tion of the collaboration between bly in 1975 reinforced the trend, delegation to the WHO origi-
the WHO and UNICEF (which declaring the construction of nated the idea of an international
could be traced to the years im- National Programs in primary conference on primary health
mediately following World War health care a matter of urgent care. Initially, the Soviet Union
II). Mahler established a close priority. The report Alternative opposed the proposal and de-
rapport with Henry Labouisse, Approaches became the basis for fended a more medically oriented
UNICEFs executive director be- a worldwide debate. In the 1976 approach for backward countries.

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PUBLIC HEALTH THEN AND NOW

However, after noticing that the cial public health institutions. It approaches. The conferences
primary health care movement was expected that many of the main document, the Declaration
was growing, the Soviet delegate delegates would be planning offi- of Alma-Ata, which was already
to the WHO declared in 1974 cers and education experts, who known by many participants, was
that his country was eager to would be able to implement an approved by acclamation. The
hold the meeting. The offer also effective intersectorial approach, term declaration suggested high
resulted from the growing compe- but few of them were. The meet- importance, like other great dec-
tition between the traditional ing was also attended by UN and larations of independence and
communist parties and the new international agencies such as human rights. The intention was
pro-Chinese organizations that the International Labor Organi- to create a universal and bold
emerged in several developing zation, the Food and Agriculture statement. This was certainly un-
countries. However, the proposal Organization, and the Agency for usual for a health agency used to
of the Soviet Union had one con- International Development. Non- compromising resolutions. The
dition: the conference should governmental organizations, reli- slogan Health for All by the
take place on Soviet soil. The So- gious movements (including the Year 2000 was included as a
viet Union was willing to fund a Christian Medical Commission), prospective view.
great part of the meeting, offering the Red Cross, Medicus Mundi, Three key ideas permeate the
$US 2 million.22 and political movements such as declaration: appropriate technol-
For a while, the WHO the Palestine Liberation Organi- ogy, opposition to medical elit-
searched for an alternative site. zation and the South West Africa ism, and the concept of health as
The governments of Iran, Egypt, Peoples Organization were also a tool for socioeconomic devel-
and Costa Rica entertained the present. However, for political opment. Regarding the first issue,
idea but finally declined. Nobody reasonsthe Sino-Soviet conflict there was criticism of the nega-
could match the economic offer had been worsening since the tive role of disease-oriented
of the Soviet Union, and in the 1960sChina was absent. technology.25 The term referred
case of Iran there was fear of po- At the opening ceremony, to technology, such as body scan-
litical instability. Finally, the Mahler challenged the delegates ners or heart-lung machines, that
WHO accepted the Soviet offer with 8 compelling questions that were too sophisticated or expen-
but asked for a different location called for immediate action. Two sive or were irrelevant to the
than Moscow, suggesting a of the most audacious were as common needs of the poor.
provincial city. After some nego- follows: Moreover, the term criticized the
tiations Alma-Ata was selected, Are you ready to introduce, creation of urban hospitals in de-
partly because of the remarkable if necessary, radical changes in veloping countries. These institu-
health improvements experi- the existing health delivery sys- tions were perceived as promot-
enced in what was a backward tem so that it properly supports ing a dependent consumer
area during Tsarist Russia. The [primary health care] as the over- culture, benefiting a minority,
event was a small Soviet victory riding health priority? and drawing a substantial share
in the Cold War. Are you ready to fight the of scarce funds and manpower.
The conference was attended political and technical battles re- Mahlers used the story of the
by 3000 delegates from 134 quired to overcome any social sorcerers apprentice to illustrate
governments and 67 interna- and economic obstacles and pro- how health technology was out
tional organizations from all over fessional resistance to the univer- of social control.26 In contrast,
the world. Details were carefully sal introduction of [primary appropriate medical technology
orchestrated by the Peruvian health care]?24 was relevant to the needs of the
David Tejada-de-Rivero, the people, scientifically sound, and
WHO assistant director general When the conference took financially feasible. In addition,
who was responsible for the place, primary health care was to the construction of health posts
event.23 Most of the delegates some degree already sold to in rural areas and shantytowns,
came from the public sector, many participants. From 1976 to instead of hospital construction,
specifically from ministries of 1978, the WHO and UNICEF was emphasized.
health; of 70 Latin American organized a series of regional The declarations second key
participants, 97% were from offi- meetings to discuss alternative idea, criticism of elitism, meant a

November 2004, Vol 94, No. 11 | American Journal of Public Health Cueto | Peer Reviewed | Public Health Then and Now | 1867
PUBLIC HEALTH THEN AND NOW

disapproval of the overspecializa- for All (1982).28 However, de- fense in the Kennedy and John-
tion of health personnel in devel- spite the initial enthusiasm, it son administrations and, since
oping countries and of top-down was difficult to implement pri- 1968, president of the World
health campaigns. Instead, train- mary health care after Alma- Bank; Maurice Strong, chairman
ing of lay health personnel and Ata. About a year after the con- of the Canadian International
community participation were ference took place, a different Development and Research Cen-
stressed. In addition, the need for interpretation of primary health ter; David Bell, vice president of
working with traditional healers care appeared. the Ford Foundation; and John J.
such as shamans and midwives Gillian, administrator of the US
was emphasized. Finally, the dec- SELECTIVE PRIMARY Agency for International Devel-
laration linked health and devel- HEALTH CARE opment, among others. The influ-
opment. Health work was per- ential McNamara was trying to
ceived not as an isolated and The Alma-Ata Declaration overcome the criticism that the
short-lived intervention but as was criticized for being too World Bank had ignored social
part of a process of improving broad and idealistic and having poverty and the fatigue of donor
living conditions. Primary health an unrealistic timetable. A com- agencies working in developing
care was designed as the new mon criticism was that the slo- countries. He promoted business
center of the public health sys- gan Health for All by 2000 management methods and clear
tem. This required an intersector- was not feasible. Concerned sets of goals, and he moved the
ial approachseveral public and about the identification of the World Bank from supporting
private institutions working to- most cost-effective health strate- large growth projects aimed at
gether on health issues (e.g., on gies, the Rockefeller Foundation generating economic growth to
health education, adequate hous- sponsored in 1979 a small con- advocating poverty reduction
ing, safe water, and basic sanita- ference entitled Health and approaches.31
tion). Moreover, the link between Population in Development at The conference was based on
health and development had po- its Bellagio Conference Center in a published paper by Julia Walsh
litical implications. According to Italy. The goal of the meeting and Kenneth S. Warren entitled
Mahler, health should be an in- was to examine the status and Selective Primary Health Care,
strument for development and interrelations of health and pop- an Interim Strategy for Disease
not merely a byproduct of eco- ulation programs when the or- Control in Developing Coun-
nomic progress: we could . . . ganizers felt disturbing signs of tries.32 The paper sought spe-
become the avant garde of an in- declining interest in population cific causes of death, paying spe-
ternational conscience for social issues.29 It is noteworthy that cial attention to the most
development.27 since the 1950s, international common diseases of infants in
The 32nd World Health As- agencies had been active in pop- developing countries such as di-
sembly that took place in ulation control and family plan- arrhea and diseases produced by
Geneva in 1979 endorsed the ning in less-developed countries. lack of immunization. The au-
conferences declaration. The as- The inspiration and initial thors did not openly criticize the
sembly approved a resolution framework for the meeting came Alma-Ata Declaration. They pre-
stating that primary health care from the physician John H. sented an interim strategy or
was the key to attaining an ac- Knowles, president of the Rocke- entry points through which basic
ceptable level of health for all. feller Foundation and editor of health services could be devel-
In the following years, Mahler Doing Better and Feeling Worse, oped. They also emphasized at-
himself became an advocate of who strongly believed in the tainable goals and cost-effective
primary health care, writing pa- need for more primary care prac- planning. In the paper, and at
pers and giving speeches with titioners in the United States.30 the meeting, selective primary
strong titles such as Health and (Knowles died a few months be- health care was introduced as
Justice (1978), The Political fore the meeting took place.) The the name of a new perspective.
Struggle for Health (1978), heads of important agencies were The term meant a package of
The Meaning of Health for All involved in the organization of low-cost technical interventions
by the Year 2000 (1981), and the meeting: Robert S. McNa- to tackle the main disease prob-
Eighteen Years to Go to Health mara, former secretary of de- lems of poor countries.

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At first, the content of the many health programs). Interest- the new director of UNICEF, he
package was not completely ingly, acute respiratory infec- asked a WHO assistant director
clear. For example, in the original tions, a major cause of infant to nourish a good relationship
paper, a number of different in- mortality in poor countries, were between the 2 organizations.
terventions were recommended, not included. These were However, a debate between the
including the administration of thought to require the adminis- 2 versions on primary health
antimalarial drugs for children tration of antibiotics that non- care was inevitable.39 Some sup-
(something that later disappeared medical practitioners in many of porters of comprehensive pri-
from all proposals). However, in the affected countries were not mary health care, as the holistic
the following years, these inter- allowed to use. or original idea of primary
ventions were reduced to 4 and Selective primary health care health care began to be called,
were best known as GOBI, which attracted the support of some considered selective primary
stood for growth monitoring, oral donors, scholars, and agencies. health care to be complemen-
rehydration techniques, breast- According to some experts, it cre- tary to the Alma-Ata Declara-
feeding, and immunization. ated the right balance between tion, while others thought it con-
The first intervention, growth scarcity and choice.36 One partic- tradicted the declaration. Some
monitoring of infants, aimed to ipant of the Bellagio meeting that members of the WHO tried to
identify, at an early stage, chil- was greatly influenced by the respond to the accusation that
dren who were not growing as new proposal was UNICEF. they had no clear targets. For
they should. It was thought that James Grant, a Harvard-trained


the solution was proper nutri- economist and lawyer, was ap-
tion. The second intervention, pointed executive director of Some supporters of comprehen-
oral rehydration, sought to con- UNICEF in January 1980 and
sive primary health care, as
trol infant diarrheal diseases served until January 1995.37
with ready-made packets known Under his dynamic leadership, the holistic or original idea of
as oral rehydration solutions.33 UNICEF began to back away primary health care began to be
The third intervention empha- from a holistic approach to pri-
called, considered selective
sized the protective, psychologi- mary health care. The son of a
cal, and nutritional value of giv- Rockefeller Foundation medical primary health care to be
ing breastmilk alone to infants doctor who worked in China, complementary to the Alma-Ata
for the first 6 months of their Grant believed that international
Declaration, while others thought


lives.34 Breastfeeding also was agencies had to do their best
considered a means for prolong- with finite resources and short- it contradicted the declaration.
ing birth intervals. The final in- lived local political opportunities.
tervention, immunization, sup- This meant translating general example, a WHO paper entitled
ported vaccination, especially in goals into time-bound specific ac- Indicators for Monitoring
early childhood.35 tions. Like Mahler, he was a Progress Towards Health for All
These 4 interventions ap- charismatic leader who had an was prepared at the urgent re-
peared easy to monitor and eval- easy way with both heads of quest of the Executive Board.40
uate. Moreover, they were meas- state and common people. A few Another publication provided
urable and had clear targets. years later, Grant organized a specific Health for All goals:
Funding appeared easier to ob- UNICEF book that proposed a 5% of gross national product de-
tain because indicators of suc- childrens revolution and ex- voted to health; more than 90%
cess and reporting could be pro- plained the 4 inexpensive inter- of newborn infants weighing
duced more rapidly. In the next ventions contained in GOBI.38 2500 g; an infant mortality rate
few years, some agencies added Mahler never directly con- of less than 50 per 1000 live
FFF (food supplementation, fe- fronted this different approach births; a life expectancy over 60
male literacy, and family plan- to primary health care. After years; local health care units
ning) to the acronym GOBI, cre- some doubts, Mahler himself at- with at least 20 essential
ating GOBI-FFF (the educational tended the Bellagio Conference, drugs.41 However, most of the
level of young women and moth- and although there is evidence supporters of primary health
ers being considered crucial to that he did not get along with care avoided these indicators,

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PUBLIC HEALTH THEN AND NOW

working in developing coun-


tries,47 partly thanks to an impor-
tant achievement: the global
eradication of smallpox in 1980.
Beginning in 1974, the WHOs
Expanded Program on Immu-
nization fought against 6 com-
municable diseases: tuberculosis,
measles, diphtheria, pertussis,
tetanus, and polio, setting a tar-
get of 80% coverage of infants
or universal childhood immu-
nization by 1990. This program
contributed to the establishment
of cold-chain equipment, ade-
quate sterilization practices, cele-
bration of National Vaccination
Days, and expanded systems of
surveillance.48
Immunization campaigns ac-
celerated in the developing
world after the mid-1980s. They
also gained the important sup-
Oral rehydration salts pro-
moted by selective primary arguing that they were unreli- artificial infant formula were port of Rotary International.49
health care were criticized in able and failed to demonstrate $2 billion a year (Third World Colombia, for example, made
this drawing as a Band-Aid. the inequities inside poor coun- nations accounted for 50% of immunization a national crusade.
(Drawing by Alicia Brelsford, tries.42 The debate between the the total).44 Companies argued Starting in 1984, it was strongly
reprinted with permission from
2 versions of primary health incorrectlythat infant formulas supported by the government
David Werner. David Werner
and David Sanders, with Jason care continued. had to be used in developing and by hundreds of teachers,
Weston, Steve Babb, and Bill countries because undernour- priests, policemen, journalists,
Rodriguez, Questioning the THE DEBATE ished mothers could not provide and Red Cross volunteers.50 In
Solution: the Politics of Primary proper nourishment and pro- 1975, only 9% of Colombian
Health Care and Child Survival,
The supporters of comprehen- longed lactation would aggravate children aged younger than 1
with an In-Depth Critique of Oral
Rehydration Therapy [Palo Alto, sive primary health care accused their health.45 In contrast, for year were covered with DPT (a
CA : HealthWrights, 1997].) selective primary health care of health advocates, who launched a vaccine that protects against
being a narrow technocentric ap- boycott against the Swiss multina- diphtheria, pertussis, and
proach that diverted attention tional Nestl, one of the main tetanus, given to children
away from basic health and so- problems was the use of unsafe younger than 7 years old). By
cioeconomic development, did water for bottle-feeding in shanty- 1989, the figure had risen to
not address the social causes of towns. This fascinating contro- 75% and in 1990 to 87%.51 In
disease, and resembled vertical versy helped to change maternal a corollary development, the in-
programs.43 In addition, critics practices in several countries but fant mortality rate decreased.
said that growth monitoring was did little to excite the enthusiasm These experiences were instru-
difficult since it required the use of donor agencies.46 mental in overcoming popular
of charts by illiterate mothers To supporters of comprehen- misperceptions such as that vac-
(recording data was not an easy sive primary health care, oral re- cination had negative side ef-
operation, weighing scales were hydration solutions were a Band- fects, was not necessary for
frequently deficient, and charts Aid in places where safe water healthy children, and was not
were subject to misinterpretation). and sewage systems did not exist. safe for pregnant women.
Breastfeeding confronted power- However, this intervention, to- However, the achievements of
ful food industries. In 1979, it gether with immunization, be- immunization did not lessen the
was estimated that global sales of came popular with agencies debate over primary health

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PUBLIC HEALTH THEN AND NOW

care.52 Newell, one of the archi- structures willing to participate in the wide range of costs . . . is in-
tects of primary health care, health programs after their lead- dicative of how little is known
made a harsh criticism: [selec- ers received the necessary infor- about this area.60
tive primary health care] is a mation was idealistic. In fact, As a result, most international
threat and can be thought of as a they said, these communities and agencies were interested in short-
counter-revolution. Rather than their learning process were usu- term technical programs with
an alternative, it . . . can be de- ally diverse and complex.56 clear budgets rather than broadly
structive. . . . Its attractions to the In its mildest version, primary defined health programs.61 In ad-
professionals and to funding health care was an addition to dition, during the 1980s many
agencies and governments look- preexisting medical services, a developing countries confronted
ing for short-term goals are very first medical contact, an exten- inflation, recession, economic ad-
apparent. It has to be rejected.53 sion of health services to rural justment policies, and suffocating
US agencies, the World Bank, areas, or a package of selective foreign debts that began to take
and UNICEF began to prioritize primary health care interven- their toll on public health re-
some aspects of GOBI, such as tions. However, none of these sources. A new political context
immunization and oral rehydra- features could avoid being con- created by the emergence of con-
tion solutions. As a result, in- sidered second-quality care, sim- servative neo-liberal regimes in
creasing tension and acrimony plified technology, or poor health the main industrialized countries
developed between the WHO care for the poor.57 Two corol- meant drastic restrictions in
and UNICEF, the 2 founding in- lary criticisms from Latin Ameri- funds for health care in develop-
stitutions of primary health care, can leftist scholars were that pri- ing countries. According to
during the early 1980s.54 mary really meant primitive Mahler, during the 1980s, Too
The debate between these 2 health care and that it was a many countries, too many bilat-
perspectives evolved around 3 means of social control of the eral and multilateral agencies,
questions: What was the mean- poor, a debasement of the gold too many individuals had be-
ing of primary health care? standard established in Alma- come too disillusioned with the
How was primary health care to Ata. A related question not an- prospects for genuine human
be financed? How was it to be swered was, Is primary health development.62
implemented? The different care cheaper than traditional The changing political context
meanings, especially of compre- health interventions or does it was also favorable for deeply in-
hensive primary health care, un- demand a greater investment?58 grained conservative attitudes
dermined its power. In its more It was not clear just after the among health professionals. For
radical version, primary health Alma-Ata meeting how primary example, most Latin American
care was an adjunct to social health care was going to be fi- physicians were trained in med-
revolution. For some, this was nanced.59 In contrast to other in- ical schools that resembled US
undesirable, and Mahler was to ternational campaigns, such as universities, were based in hospi-
be blamed for transforming the the global malaria eradication tals, lived in cities, received a
WHO from a technical into a program of the 1950s, where high income by local standards,
politicized organization.55 UNICEF and US bilateral assis- and belonged to the upper and
For others, however, it was tance provided funding, there upper-middle classes.63 They per-
nave to expect such changes were no significant resources in ceived primary health care as
from the conservative bureaucra- the WHO for training auxiliary anti-intellectual, promoting
cies of developing countries. Ac- personnel, improving nutrition pragmatic nonscientific solutions
cording to their view, it was sim- and drinking water, or creating and demanding too many self-
plistic to assume that enlightened new health centers. It was diffi- sacrifices (few would consider
experts and bottom-up commu- cult to convince developing moving to the rural areas or
nity health efforts had a revolu- countries to change their already shantytowns). A minority of med-
tionary potential, and the politi- committed health budgets. A ical doctors who embraced pri-
cal power of the rural poor was 1986 study examined several es- mary health care thought that it
underestimated. They also timates of primary health care in should be conducted under the
thought that the view of com- developing countries (around close supervision of qualified pro-
munities as single pyramidal US$1 billion) and concluded that fessional personnel. Frequently,

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PUBLIC HEALTH THEN AND NOW

they distrusted lay personnel support of the WHOs bureau- this article illustrate 2 diverse as- tion of sound technical interven-
working as medical auxiliaries. cracy, and his allies outside sumptions in international health tions, socioeconomic develop-
In a 1980 speech, Mahler had WHO were not always available. in the 20th century. First, there ment programs, and the training
already complained about the For example, from 1984 to was a recognition that diseases in of human resources for health is
medical emperors and their 1987, an important US scholar less-developed nations were so- the study of history.
negativism toward primary for primary health care, Carl cially and economically sustained
health care because of false Taylor, left Johns Hopkins and and needed a political response.
pompous grandeur.64 The con- was a UNICEF representative in Second, there was an assumption About the Author
The author is with the Department of
frontation made matters worse. China. In 1985, Tejada-de-Rivero, that the main diseases in poor
Sociomedical Sciences, School of Public
The resistance of medical profes- one of Mahlers main assistants countries were a natural reality Health, Universidad Peruana Cayetano
sionals became more acute since at Geneva, moved permanently that needed adequate technologi- Heredia, Lima, Peru.
Requests for reprints should be sent to
they feared losing privileges, to Peru, where he became minis- cal solutions. These 2 ideas were
Marcos Cueto, PhD, Roca Bologna 633,
prestige, and power. Confronta- ter of health. In 1988, Mahler takeneven before primary Lima 18, Peru (e-mail: mcueto@upch.edu.pe).
tion continued since there was ended a 3-term period as direc- health careas representing a This article was accepted March 13,
2004.
no steady effort to reorganize tor general of the WHO. Al- dilemma, and one path or the
medical education around pri- though he never officially other had to be chosen.
Acknowledgments
mary health care or to enhance launched a reelection campaign, I have illustrated the crucial Research for this article was made possi-
the prestige of lay personnel. no one appeared who was sec- interaction between the context, ble thanks to the Council for Interna-
However, for a generation of ond-in-command or had suffi- the actors, the targets, and the tional Exchange of ScholarsFulbright
New Century Scholars Program Chal-
Latin American medical students, cient energy to keep promoting techniques in international lenges of Health in a Borderless World
primary health care became an primary health care against all health. Primary health care and and the Joint Learning Initiative for
introduction to public health and odds. In a confusing election and selective primary health care rep- Human Resources for Health and Devel-
opment. The article was completed dur-
Mahler a sort of icon. an unexpected turn of events, resent different arrangements of ing 2004 when the author was a visit-
Another problem of primary the Japanese physician Hiroshi these 4 factors. In the case of pri- ing fellow at the Woodrow Wilson
health care implementation was Nakajima was elected as the new mary health care, the combina- Center in Washington, DC.

real political commitment. Some director general. tion can be summarized as the
Latin American authoritarian Nakajima lacked the commu- crisis of the Cold War, the promi- Endnotes
regimes, such as the military nication skills and charismatic nence of Mahler at the WHO, 1. S. Litsios, The Long and Difficult
Road to Alma-Ata: A Personal Reflec-
regime in Argentina, formally en- personality of his predecessor. the utopian goal of Health for tion, International Journal of Health Ser-
dorsed the Alma-Ata Declaration His election can be considered to All, and an unspecific method- vices 32 (2002): 709732; S. Lee,
but did not implement any tangi- mark the end of the first period ology. The combination in the WHO and the Developing World: The
Context for Ideology, in Western Medi-
ble reform. Because most inter- of primary health care. The case of selective primary health cine as Contested Knowledge, ed. A. Cun-
national agencies favored selec- WHO seemed to trim primary care was neo-liberalism, the ningham and B. Andrews (Manchester:
tive primary health care, many health care, and most impor- leadership of Grant as head of Manchester University Press, 1997),
2445.
Latin American ministries of tantly, the WHO lost its political UNICEF, the more modest goal
2. J. H. Bryant, Health and the Devel-
health created an underfunded profile. In a corollary develop- of a childrens revolution, and
oping World (Ithaca, NY: Cornell Uni-
primary health care program in ment, a 1997 Pan American GOBI interventions. versity Press, 1969), ixx.
their fragmented structures and Health Organization document A lesson of this story is that 3. C. E. Taylor, ed., Doctors for the
concentrated on 1 or 2 of the proposed a new target, or a new the divorce between goals and Villages: Study of Rural Internships in
Seven Indian Medical Colleges (New
GOBI interventions. As a re- deadline, entitled Health for All techniques and the lack of articu-
York: Asia Publishing House, 1976).
sult, the tension between those in the 21st Century. 65 Support- lation between different aspects
4. K. W. Newell, Health by the People
who advocated vertical, disease- ers of a holistic primary health of health work need to be ad- (Geneva: World Health Organization
oriented programs and those care believed that the original dressed. A holistic approach, ide- [WHO], 1975), xi.
who advocated community- proposal largely remained on the alism, technical expertise, and fi- 5. Canadian Department of National
Health and Welfare, A New Perspective
oriented programs was accepted drawing board,66 a claim still nance shouldmustgo together.
on the Health of Canadians/Nouvelle per-
as a normal state of affairs. made today. There are still problems of terri- spective de la sante des Canadiens (Ot-
During the mid-1980s, toriality, lack of flexibility, and tawa: n. p., 1974).
Mahler continued his crusade for CONCLUSION fragmentation in international 6. T. McKeown, The Modern Rise of
Population (New York: Academic Press,
a more holistic primary health agencies and health programs in
1976).
care in different forums. How- The history of the origins of developing countries. Primary
7. I. Illich, Medical Nemesis: the Expro-
ever, he was frequently alone, primary health care and selective and vertical programs coexist. priation of Health (London: Calder &
since he did not have the full primary health care analyzed in One way to enhance the integra- Boyars, 1975).

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PUBLIC HEALTH THEN AND NOW

8. G. Paterson, The CMC Story, cial Council, United Nations Childrens 1776, Rockefeller Archive Center, the Issues Concerning Comprehensive
19681998, Contact 161162 (1998): Fund, Executive Board, 29 October Sleepy Hollow, NY (hereafter RAC). Primary Health Care and Selective Pri-
318. 1976, Folder WHO International Con- mary Health Care, Social Science and
30. J. H. Knowles, ed., Doing Better and
9. R. Martin, Christians Pioneer In- ference on Primary Health Care 1978, Medicine 23 (1986): 559566; J. P.
Feeling Worse (New York: W.W. Norton
ternational Health Concepts, available August 1975February 1977, Unger and J. Killingsworth, Selective Pri-
and Co., 1977).
at http://www.ccih.org/forum/0011- P/21/87/5, WHO Archive. mary Health Care: A Critical Review of
31. J. H. Knowles to C. Wahren, July 6, Methods and Results, Social Science and
03.htm, accessed March 19, 2004. 23. Tejada-de-Rivero had great care for 1978, Folder Health and Population, Medicine 10 (1986): 10011002; the
10. V. W. Sidel, The Barefoot Doctors the details of organizing the meeting, RFA, RG A82, Series 120, Box 1776, special issue Selective or Comprehen-
of the Peoples Republic of China, New shown in his request for 250 desks RAC; Martha Finnemore, Redefining sive Primary Health Care of Social Sci-
England Journal of Medicine 286 and tables, 500 chairs, 200 typist Development at the World Bank, in In- ence and Medicine 26(9) (1988).
(1972): 12921300. See also R. Sidel desks, 200 typist chairs, among other ternational Development and the Social
and V. Sidel, Health Care and Traditional items; D. Tejada-de-Rivero to D. Science: Essays in the History and Politics 40. WHO Indicators for Monitoring
Medicine in China, 18001982 (Lon- Venediktov, September 20, 1976, of Knowledge, ed. F. Cooper and R. Progress Towards Health for All: Discus-
don: Routledge and Kegan, 1982). Folder WHO International Conference Packard (Berkeley: University of Califor- sion Paper, Geneva March 17, 1980,
on Primary Health Care 1978 August nia Press, 1997), 203227. HPC/MPP/DPE/80.2, WHO Library,
11. L. B. Pearson, Partners in Develop- 1975February 1977, P 21/87/5. Geneva.
ment (New York: Praeger, 1969); W. WHO Archive. 32. J. A. Walsh and K. S. Warren, Se-
Brandt, NorthSouth, A Program for Sur- lective Primary Health Care, an Interim 41. Primary Health: A First Assess-
vival (Cambridge, Mass: MIT Press, 24. Intervention of Director General Strategy for Disease Control in Develop- ment, People Report on Primary Health
1980). of WHO, H. Mahler, in Alma Ata ing Countries, New England Journal of Care (1985): 69, WHO Library,
1978, International Conference on Pri- Medicine 301 (1979): 967974; it also Geneva.
12. L. A. Hoskins, The New Interna-
mary Health Care, 612 September appeared in Social Science and Medicine
tional Economic Order: A Bibliographic 42. Venediktov, Lessons, 336.
1978, Statements by Participants in the 14C (1980): 145163 as part of an
Essay, Third World Quarterly 3 (1981): 43. O. Gish, Selective Primary Care:
Plenary Meetings, 46, ICPHC/ALA/ issue devoted to the Bellagio meeting.
506527. Old Wine in New Bottles, Social Sci-
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13. The biographical information is 33. J. Ruxin, Magical Bullet: The His- ence and Medicine 16 (1982): 1054.
25. See H. T. Mahler, HealthA De- tory of Oral Rehydration Therapy,
taken from Dr Halfdan T. Mahler,
mystification of Medical Technology, Medical History 38 (1991): 363397. 44. J. E. Post [associate professor of
available at http://www.who.int/
Lancet ii (1975): 829833. management policy at Boston University
archives/wh050/en/directors.htm, 34. S. Plank and M. L. Milanesi, Infant School of Management] to R. Bartley
accessed March 19, 2004. 26. H. T. Mahler, World Health Is Feeding and Infant Mortality in Rural [editor of the Wall Street Journal], No-
Indivisible: Address to the Thirty-First Chile, Bulletin of the World Health Or-
14. H. T. Mahler, interview with the vember 13, 1979, Folder The Protec-
World Health Assembly (Geneva: ganization 48 (1973): 203210.
author, Geneva, May 2002. tion and Promotion of Breast Feeding,
WHO, 1978), 4.
15. Mac McGivray (a CMC member) 35. Protecting the Worlds Children: CF-NYH-09 D 5-81 Heyward T011 A
after a meeting with Mahler on March 27. H. T. Mahler, WHOs Mission Re- Vaccines and Immunization Within Pri- 138, UNICEF Archives, New York, NY.
22, 1974. Cited in Paterson, The CMC visited: Address in Presenting His Re- mary Health Care, Conference Report 45. H. I. Sheefild, Boycott to Save
Story, 13. port for 1974 to the 28th World Health (New York: Rockefeller Foundation, Lives of Third World Babies, Michigan
Assembly, 15 May 1975, 10, Mahler 1984).
16. V. Djukanovic and E. P. Mach, eds., Chronicle, December 29, 1979 [newspa-
Speeches/Lectures, Box 1, WHO Li-
Alternative Approaches to Meeting Basic 36. J. Evans, K. Hall, and J. Warford, per clipping], Folder The Protection
brary, Geneva.
Health Needs of Populations in Develop- Health Care in the Developing World: and Promotion of Breastfeeding, CF-
ing Countries: A Joint UNICEF/WHO 28. WHA32.30, Formulating Strate- Problems of Scarcity and Choice, New NYH-09 D 05-81 Heyward T011
Study (Geneva: WHO, 1975), 110. gies for Health for all by the Year England Journal of Medicine 305 A138, UNICEF Archives.
2000, World Health Organization, (1981): 11171127.
17. The Work of WHO in 1972: An- 46. Criticism Mounts Over Use of
32nd World Health Assembly, Geneva,
nual Report of the Director General to 37. On Grant, see C. Bellamy, P. Baby Formulas Among Worlds Poor,
725 May 1979, available at http://
the World Health Assembly, in WHO Adamson, S. B. Tacon, et al., Jim Grant: Washington Post, April 21, 1981 [news-
policy.who.int/cgi-bin/ om_isapi.dll?
Official Records 205, 1973, Geneva, UNICEF Visionary (Florence, Italy: paper clipping], Folder The Protection
infobase=WHA&softpage=Browse_Fra
WHO Library. UNICEF Innocenti Research Center, and Promotion of breastfeeding, CF-
me_Pg42, accessed June 25, 2004; H.
2001), available at http://www.unicef. NYH-09 D 05-81 Heyward T011
18. Djukanovic and Mach, Alternative T. Mahler, Salud con Justicia, Salud
org/ about/who/index_bio_grant.html, A138, UNICEF Archives; J. E. Post and
Approaches, 14. Mundial (May 1978); What Is Health
accessed March 19, 2004. E. Baer, The International Code of
19. H. T. Mahler, Social Perspectives for All? World Health (November
Marketing for Breast Milk Substitutes:
in Health: Address in Presenting His Re- 1979): 35; Mahler, The Meaning of 38. UNICEF, The State of the Worlds
Consensus, Compromise and Conflict
port for 1975 to the Twenty-Ninth Health for All by the Year 2000, Children: 1982/1983 (New York: Ox-
in the Infant Formula Controversy,
World Health Assembly, Geneva, 4 World Health Forum 2 (1981): 522; ford University Press, 1983). See also K.
The Review: International Commission
May 1976, 1, Mahler Speeches/Lec- Mahler, The Political Struggle for S. Warren, Introduction, in Strategies
of Jurists 25 (December 1980):
tures, Box 1, WHO Library. Health: Address at the 29th Session of for Primary Health Care: Technologies
5261; M. B. Bader, Breast-Feeding:
WHO Regional Committee for the Appropriate for the Control of Disease in
20. Interview with David Tejada-de- The Role of the Multinational Corpora-
Western Pacific; Mahler, Eighteen the Developing World, ed. J. Walsh and
Rivero, in World Federation of Public tions in Latin America, International
Years to Go to Health for All, Address K. S. Warren (Chicago: University of
Health Associations, Conference Bulletin 1 Journal of Health Services 6 (1976):
to the 21st Pan American Sanitary Con- Chicago, 1986), ixxi; K. S. Warren,
(1977): 1, Folder WHO International 604626.
ference, Geneva (all Mahler articles The Evolution of Selective Primary
Conference on Primary Health Care from Mahler Speeches/Lectures, Box 1, Health Care, Social Science and Medi- 47. During these years, most develop-
1978, November 1977January 1978, WHO Library, Geneva). cine 26 (1988): 891898. ing countries significantly improved the
P/21/87/5, WHO Archive, Geneva. coverage figures. Expanded Pro-
29. K. Kanagaratnam, A Review of 39. Examples of the debate are the let-
21. D. D. Venediktov, Primary Health gramme on Immunization, November
the Bellagio Population and Health Pa- ters sent to the editor that appeared in
Care: Lessons From Alma Ata, World 24, 1978, Folder WHO-UNICEF Joint
pers, May 9, 1979, Folder Health and the Correspondence section of the New
Health Forum 2 (1981): 332340, Study, CF-NYH-09 D Heyward T010
Population, Rockefeller Foundation England Journal of Medicine 302 (1980):
quote from p. 333. A128, UNICEF Archives.
Archives (hereafter RFA), Record Group 757759. See also S. Rifkin and G.
22. United Nations Economic and So- (hereafter RG) A82, Series 120, Box Walt, Why Health Improves: Defining 48. T. Hill, R. Kim-Farley, and J.

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Rohde, Expanded Programme on Im- 59. The concern appears in some


munization: A Goal Achieved Towards UNICEF documents, such as Memo-
Health for All, in Reaching Health For randum From F. L. Fazzi, December
All, ed. J. Rohde, M. Chatterjee, and D. 22,1977 Un-edited Redraft on Budget-
Morley (Delhi: Oxford University Press, ing of [Primary Health Care], Folder
1993), 403422. WHO and UNICEF Fund Raising, CF- NEW
49. G. Nossal, Protecting Our Prog-
NYH-09 D, UNICEF Archives. from
eny: The Future of Vaccines, Perspec-
tives in Health Magazine 7 (2002):
60. M. Patel, An Economic Evaluation
of Health For All, Health and Policy and
APHA
813. Planning 1 (1986): 3747.
50. UNICEF, UNICEF in the Americas, 61. S. B. Rifkin, F. Muller, and V. Bich-
for the Children of Three Decades, mann, Primary Health Care: On Mea-
UNICEF, History Series 85, Monograph suring Participation, Social Science and
IV, 1995, UNICEF Library, New York
City.
Medicine 26 (1988): 931940. The Face of
51. F. Muller, Participation, Poverty
62. H. T. Mahler, World Health 2000
and Beyond: Address to the 41st World Public Health
and Violence: Health and Survival in Health Assembly 3 May 1984, Mahler
Latin America, in Reaching Health for Speeches/Lectures, Box 1, WHO Li-
All, 103129.
52. There were even radical critiques
of the original Alma Ata Declaration,
brary.
63. A. J. Rubel, The Role of Social Sci-
ence Research in Recent Health Pro-
A PHA has created a new video
that health advocates can use
to explain the important work car-
such as V. Navarro, A Critique of the grams in Latin America, Latin Ameri-
Ideological and Political Positions of the can Research Review 2 (1966): 3756. ried out every day by the public
Willy Brandt Report and the WHO
64. H. T. Mahler, Primary Health Care, health community.
Alma Ata Declaration [1984], in V.
Navarro, Crisis, Health and Medicine: A
an Analysis of Some Constraints, an Ad- In this moving video, the people
dress Delivered to the Special Congrega-
Social Critique (London: Tavistock Publi-
tion for the Conferment of an Honorary
of public health share what they do
cations, 1986), 212232.
Degree on Dr. Halfan T. Mahler at the and how their work improves and
53. K. W. Newell, Selective Primary University of Lagos (Lagos: University of
protects the lives of those in their
Health Care: The Counter Revolution, Lagos Press, 1980), 10, Mahler
Social Science and Medicine 26 (1988): Speeches/Lectures, Box 1, WHO Li- communities. From healthy life-
903906, quote from p. 906. brary, Geneva. styles and immunizations to policy
54. J. Goodfield, A Chance to Live (New 65. Pan American Health Organiza- development and global health,
York: McMillan International, 1991), tion, Salud para Todos en el Siglo Veinti-
2542. nuno (Washington, DC: PAHO, 1997). youll see the face of public health
55. Mahler himself mentions it in H. T. 66. D. Werner and D. Sanders, Ques- working for all of us.
Mahler, The Political Struggle for tioning the Solution: The Politics of Pri-
Health: Address of the Director General mary Health Care and Child Survival, Stock No.: 0-87553-033-8
at the 29th Session of the Regional With an In-Depth Critique of Oral Rehy- 8 minutes color 2004
Committee for the Western Pacific, dration Therapy (Palo Alto, Calif: Health $13.99 APHA Members
Manila, August 21, 1978, Mahler Rights, 1997). See also Round Table: $19.99 Nonmembers
Speeches/Lectures, Box 1, WHO Li- [Primary Health Care]What Still plus shipping and handling
brary, Geneva. Needs to Be Done? World Health
Forum 11 (1990): 359366.
56. A. W. Parker, J. M. Walsh, and American Public Health Association
M. A. Coon, Normative Approach to Publication Sales
the Definition of Primary Health Care, Web: www.apha.org
Milbank Memorial Fund Quarterly 54 E-mail: APHA@TASCO1.com
(1976): 415438. Tel: (301) 893-1894
FAX: (301) 843-0159 VID04J4
57. See J. Frenk, First Contact, Simpli-
fied Technology or Risk Anticipation?
Defining Primary Health Care, Acade-
mic Medicine 65 (1990): 676679.
58. See J. Breilh, Community Medi-
cine Under Imperialism: A New Medical
Police, International Journal of Health
Services 9 (1979): 524; M. Testa,
Atencin Primaria o primitiva? De
Salud, in Segundas Jornadas de Atencin
Primaria de la Salud (Buenos Aires: Aso-
ciacin de Mdicos Residentes del Hos-
pital de Nios Ricardo Gutirrez, 1988),
7590; A. Ugalde, Ideological Dimen-
sions of Community Participation in
Latin American Health Programs, So-
cial Science and Medicine 21 (1985):
4153.

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