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American Journal of Public Health | November 2004, Vol 94, No. 111864 | Public Health Then and Now | Peer Reviewed | Cueto

spray guns and vaccinatingsyringes.”2

In a similar perspective, CarlTaylor, founder and chairman ofthe Department of InternationalHealth at Johns Hopkins Univer-sity, edited a book that offeredIndian rural medicine as a gen-eral model for poor countries.3

Another influential work was byKenneth W. Newell, a WHO staffmember from 1967, who col-lected and examined the experi-ences of medical auxiliaries indeveloping countries. In Healthby the People, he argued that “astrict health sectorial approachis ineffective.”4 In addition, the1974 Canadian Lalonde Report(named after the minister ofhealth) deemphasized the impor-tance attributed to the quantity ofmedical institutions and proposed4 determinants of health: biology,health services, environment, andlifestyles.5

Other studies, written fromoutside the public health commu-nity, were also influential in chal-lenging the assumption thathealth resulted from the transfer-ence of technology or more doc-tors and more services. The

DURING THE PAST FEWdecades, the concept of primaryhealth care has had a significantinfluence on health workers inmany less-developed countries.However, there is little under-standing of the origins of theterm. Even less is known of thetransition to another version ofprimary health care, best knownas selective primary health care.In this article, I trace these ori-gins and the interaction be-tween 4 crucial factors for inter-national health programs: thecontext in which they appeared,the actors (personal and institu-tional leaders), the targets thatwere set, and the techniquesproposed. I use contemporarypublications, archival informa-tion, and a few interviews to lo-cate the beginnings of theseconcepts. I emphasize the roleplayed by the World Health Or-ganization (WHO) and UNICEFin primary health care and se-lective primary health care. Theexamples are mainly drawnfrom Latin America. The workis complementary to recentstudies on the origin of primaryhealth care.1

PUBLIC HEALTH THEN AND NOW

| Marcos Cueto, PhD

BACKGROUND ANDCONTEXT

During the final decades of theCold War (the late 1960s andearly 1970s) the US was em-broiled in a crisis of its ownworld hegemony—it was in thispolitical context that the conceptof primary health care emerged.By then, the so-called verticalhealth approach used in malariaeradication by US agencies andthe WHO since the late 1950swere being criticized. New pro-posals for health and develop-ment appeared, such as JohnBryant’s book Health and the De-veloping World (also published inMexico in 1971), in which hequestioned the transplantation ofthe hospital-based health caresystem to developing countriesand the lack of emphasis on pre-vention. According to Bryant,“Large numbers of the world’speople, perhaps more than half,have no access to health care atall, and for many of the rest, thecare they receive does not an-swer the problems they have . . .the most serious health needscannot be met by teams with

I present a historical study of therole played by the World Health Or-ganization and UNICEF in the emer-gence and diffusion of the concept ofprimary health care during the late1970s and early 1980s. I have ana-lyzed these organizations’ politicalcontext, their leaders, the method-ologies and technologies associatedwith the primary health care per-spective, and the debates on themeaning of primary health care.

These debates led to the develop-ment of an alternative, more restrictedapproach, known as selective primaryhealth care. My study examined libraryand archival sources; I cite examplesfrom Latin America.

ORIGINS of Primary Health CareThe

and SELECTIVE Primary Health Care

office of the World Council ofChurches (and 50 WHO staff re-ceived Contact ).9

Another important inspirationfor primary health care was theglobal popularity that the mas-sive expansion of rural medicalservices in Communist China ex-perienced, especially the “bare-foot doctors.” This visibility co-incided with China’s entranceinto the United Nations (UN)system (including the WHO).The “barefoot doctors,” whosenumbers increased dramaticallybetween the early 1960sand the Cultural Revolution(1964–1976), were a diversearray of village health workerswho lived in the communitythey served, stressed rural ratherthan urban health care and pre-ventive rather than curativeservices, and combined Westernand traditional medicines.10

Primary health care was alsofavored by a new political contextcharacterized by the emergenceof decolonized African nationsand the spread of national, anti-imperialist, and leftist movementsin many less-developed nations.These changes led to new pro-posals on development made bysome industrialized countries.Modernization was no longerseen as the replication of themodel of development followedby the United States or WesternEurope. For example, Prime Min-ister Lester B. Pearson of Canadaand Chancellor Willy Brandt ofWest Germany chaired majorcommissions on international de-velopment emphasizing long-termsocioeconomic changes instead ofspecific technical interventions.11

In a corollary decision, in 1974the UN General Assemblyadopted a resolution on the “Es-tablishment of a New Interna-tional Economic Order” to upliftless-developed countries.12

NEW ACTORS AND NEWHEALTH INTERVENTIONS

New leaders and institutionsembodied the new academic andpolitical influences. Prominentamong them was Halfdan T.Mahler of Denmark. He waselected the WHO’s director gen-eral in 1973 and was later re-elected for 2 successive 5-yearterms, remaining at its head until1988. Mahler’s background wasnot related to malariology, thediscipline that dominated inter-national health during the1950s. His first international ac-tivities were in tuberculosis andcommunity work in less-devel-oped countries. Between 1950and 1951, he directed a RedCross antituberculosis campaignin Ecuador and later spent sev-eral years (1951–1960) in Indiaas the WHO officer at the Na-tional Tuberculosis Program. In1962, he was appointed chief ofthe Tuberculosis Unit at theWHO headquarters.13 In Geneva,Mahler also directed the WHOProject on Systems Analysis, aprogram that implied improvingnational capabilities in healthplanning.

More importantly, Mahler wasa charismatic figure with a mis-sionary zeal. His father, a Baptistpreacher, helped shape his per-sonality. Many years after his re-tirement from the WHO, he ex-plained that for him, “socialjustice” was a “holy word.”14 Thestrong impression he produced insome people is well illustrated bya religious activist who metMahler in the 1970s: “I felt like achurch mouse in front of anarchbishop.”15

Mahler had excellent relationswith older WHO officers. TheBrazilian malariologist MarcolinoCandau, the WHO director gen-eral before Mahler, appointed the


British historian Thomas Mc-Keown argued that the overallhealth of the population was lessrelated to medical advances thanto standards of living and nutri-tion.6 More aggressively, Ivan Il-lich’s Medical Nemesis contendedthat medicine was not only irrele-vant but even detrimental, be-cause medical doctors expropri-ated health from the public. Thisbook became a bestseller andwas translated into several lan-guages, including Spanish.7

Another important influencefor primary health care camefrom the experience of mission-aries. The Christian MedicalCommission, a specialized organ-ization of the World Council ofChurches and the LutheranWorld Federation, was created inthe late 1960s by medical mis-sionaries working in developingcountries.8 The new organizationemphasized the training of vil-lage workers at the grassrootslevel, equipped with essentialdrugs and simple methods. In1970, it created the journal Con-tact, which used the term pri-mary health care, probably forthe first time. By the mid-1970s,French and Spanish versions ofthe journal appeared and its cir-culation reached 10 000.

It is worth noting that JohnBryant and Carl Taylor weremembers of the Christian MedicalCommission and that in 1974 col-laboration between the commis-sion and the WHO was formal-ized. In addition, in Newell’sHealth by the People, some of theexamples cited were ChristianMedical Commission programswhile others were brought to theattention of the WHO by commis-sion members. A close collabora-tion between these organizationswas also possible because theWHO headquarters in Genevawere situated close to the main

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

Halfdan T. Mahler, director general ofthe World Health Organization,1973–1988.

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Dane as an assistant director gen-eral in 1970. Thanks to his closerelationship with the WHO’s oldguard, Mahler could ease thetransition experienced by thisagency under his command.Some of these changes occurredbefore Mahler assumed the postof director general. From the late1960s, there was an increase inWHO projects related to the de-velopment of “basic health serv-ices” (from 85 in 1965 to 156 in1971).16 These projects were in-stitutional predecessors of the pri-mary health care programs thatwould later appear. Another earlyexpression of change was the cre-ation in 1972 of a WHO Divisionof Strengthening of Health Ser-vices. Newell, a strong academicand public health voice for pri-mary health care, was appointeddirector of this division (Newell’scareer with the WHO started in1967 as director of the Divisionof Research in Epidemiology andCommunications Science).

In 1973, the year of Mahler’sappointment as the WHO direc-tor general, the Executive Boardof WHO issued the report Orga-nizational Study on Methods ofPromoting the Development ofBasic Health Services.17 This re-port was the basis for a redefini-tion of the collaboration betweenthe WHO and UNICEF (whichcould be traced to the years im-mediately following World WarII). Mahler established a closerapport with Henry Labouisse,UNICEF’s executive director be-

World Health Assembly, Mahlerproposed the goal of “Health forAll by the Year 2000.” The slo-gan became an integral part ofprimary health care. Accordingto Mahler, this target required aradical change. In a movingspeech that he delivered at the1976 assembly, he said that“Many social evolutions and rev-olutions have taken place be-cause the social structures werecrumbling. There are signs thatthe scientific and technical struc-tures of public health are alsocrumbling.”19 These ideas wouldbe confirmed at a conferencethat took place in the SovietUnion.

ALMA-ATA

The landmark event for pri-mary health care was the Inter-national Conference on PrimaryHealth Care that took place atAlma-Ata from September 6 to12, 1978. Alma-Ata was thecapital of the Soviet Republic ofKazakhstan, located in the Asi-atic region of the Soviet Union.According to one of its organiz-ers, the meeting would tran-scend the “provenance of agroup of health agencies” and“exert moral pressure” for pri-mary health care.20 A Russianco-organizer claimed that “neverbefore [have] so many countriesprepared so intensively for aninternational conference.”21

The then-current tensionamong communist countriesplayed an important role in theselection of the site. The Chinesedelegation to the WHO origi-nated the idea of an internationalconference on primary healthcare. Initially, the Soviet Unionopposed the proposal and de-fended a more medically orientedapproach for backward countries.

tween 1965 and 1979, who hadhis own rich experience withcommunity-based initiatives inhealth and education. The agree-ment produced in 1975 a jointWHO–UNICEF report, Alterna-tive Approaches to Meeting BasicHealth Needs in Developing Coun-tries, that was widely discussedby these agencies. The term “al-ternative” underlined the short-comings of traditional verticalprograms concentrating on spe-cific diseases. In addition, the as-sumption that the expansion of“Western” medical systemswould meet the needs of thecommon people was again highlycriticized. According to the docu-ment, the principal causes ofmorbidity in developing coun-tries were malnutrition and vec-tor-borne, respiratory, and diar-rheal diseases, which were“themselves the results of pov-erty, squalor and ignorance.”18

The report also examined suc-cessful primary health care expe-riences in Bangladesh, China,Cuba, India, Niger, Nigeria, Tan-zania, Venezuela, and Yugoslaviato identify the key factors in theirsuccess.

This report shaped WHOideas on primary health care.The 28th World Health Assem-bly in 1975 reinforced the trend,declaring the construction of“National Programs in primaryhealth care” a matter “of urgentpriority.” The report AlternativeApproaches became the basis fora worldwide debate. In the 1976

“”

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

care programs that would later appear.



However, after noticing that theprimary health care movementwas growing, the Soviet delegateto the WHO declared in 1974that his country was eager tohold the meeting. The offer alsoresulted from the growing compe-tition between the traditionalcommunist parties and the newpro-Chinese organizations thatemerged in several developingcountries. However, the proposalof the Soviet Union had one con-dition: the conference shouldtake place on Soviet soil. The So-viet Union was willing to fund agreat part of the meeting, offering$US 2 million.22

For a while, the WHOsearched for an alternative site.The governments of Iran, Egypt,and Costa Rica entertained theidea but finally declined. Nobodycould match the economic offerof the Soviet Union, and in thecase of Iran there was fear of po-litical instability. Finally, theWHO accepted the Soviet offerbut asked for a different locationthan Moscow, suggesting aprovincial city. After some nego-tiations Alma-Ata was selected,partly because of the remarkablehealth improvements experi-enced in what was a backwardarea during Tsarist Russia. Theevent was a small Soviet victoryin the Cold War.

The conference was attendedby 3000 delegates from 134governments and 67 interna-tional organizations from all overthe world. Details were carefullyorchestrated by the PeruvianDavid Tejada-de-Rivero, theWHO assistant director generalwho was responsible for theevent.23 Most of the delegatescame from the public sector,specifically from ministries ofhealth; of 70 Latin Americanparticipants, 97% were from offi-

cial public health institutions. Itwas expected that many of thedelegates would be planning offi-cers and education experts, whowould be able to implement aneffective intersectorial approach,but few of them were. The meet-ing was also attended by UN andinternational agencies such asthe International Labor Organi-zation, the Food and AgricultureOrganization, and the Agency forInternational Development. Non-governmental organizations, reli-gious movements (including theChristian Medical Commission),the Red Cross, Medicus Mundi,and political movements such asthe Palestine Liberation Organi-zation and the South West AfricaPeople’s Organization were alsopresent. However, for politicalreasons—the Sino-Soviet conflicthad been worsening since the1960s—China was absent.

At the opening ceremony,Mahler challenged the delegateswith 8 compelling questions thatcalled for immediate action. Twoof the most audacious were asfollows:

• Are you ready to introduce,if necessary, radical changes inthe existing health delivery sys-tem so that it properly supports[primary health care] as the over-riding health priority?

• Are you ready to fight thepolitical and technical battles re-quired to overcome any socialand economic obstacles and pro-fessional resistance to the univer-sal introduction of [primaryhealth care]?24

When the conference tookplace, primary health care was tosome degree already “sold” tomany participants. From 1976 to1978, the WHO and UNICEForganized a series of regionalmeetings to discuss “alternative

approaches.” The conference’smain document, the Declarationof Alma-Ata, which was alreadyknown by many participants, wasapproved by acclamation. Theterm “declaration” suggested highimportance, like other great dec-larations of independence andhuman rights. The intention wasto create a universal and boldstatement. This was certainly un-usual for a health agency used tocompromising resolutions. Theslogan “Health for All by theYear 2000” was included as aprospective view.

Three key ideas permeate thedeclaration: “appropriate technol-ogy,” opposition to medical elit-ism, and the concept of health asa tool for socioeconomic devel-opment. Regarding the first issue,there was criticism of the nega-tive role of “disease-orientedtechnology.”25 The term referredto technology, such as body scan-ners or heart-lung machines, thatwere too sophisticated or expen-sive or were irrelevant to thecommon needs of the poor.Moreover, the term criticized thecreation of urban hospitals in de-veloping countries. These institu-tions were perceived as promot-ing a dependent consumerculture, benefiting a minority,and drawing a substantial shareof scarce funds and manpower.Mahler’s used the story of thesorcerer’s apprentice to illustratehow health technology was outof “social” control.26 In contrast,“appropriate” medical technologywas relevant to the needs of thepeople, scientifically sound, andfinancially feasible. In addition,the construction of health postsin rural areas and shantytowns,instead of hospital construction,was emphasized.

The declaration’s second keyidea, criticism of elitism, meant a



for All” (1982).28 However, de-spite the initial enthusiasm, itwas difficult to implement pri-mary health care after Alma-Ata. About a year after the con-ference took place, a differentinterpretation of primary healthcare appeared.

SELECTIVE PRIMARYHEALTH CARE

The Alma-Ata Declarationwas criticized for being toobroad and idealistic and havingan unrealistic timetable. A com-mon criticism was that the slo-gan “Health for All by 2000”was not feasible. Concernedabout the identification of themost cost-effective health strate-gies, the Rockefeller Foundationsponsored in 1979 a small con-ference entitled “Health andPopulation in Development” atits Bellagio Conference Center inItaly. The goal of the meetingwas to examine the status andinterrelations of health and pop-ulation programs when the or-ganizers felt “disturbing signs ofdeclining interest in populationissues.”29 It is noteworthy thatsince the 1950s, internationalagencies had been active in pop-ulation control and family plan-ning in less-developed countries.

The inspiration and initialframework for the meeting camefrom the physician John H.Knowles, president of the Rocke-feller Foundation and editor ofDoing Better and Feeling Worse,who strongly believed in theneed for more primary care prac-titioners in the United States.30

(Knowles died a few months be-fore the meeting took place.) Theheads of important agencies wereinvolved in the organization ofthe meeting: Robert S. McNa-mara, former secretary of de-

fense in the Kennedy and John-son administrations and, since1968, president of the WorldBank; Maurice Strong, chairmanof the Canadian InternationalDevelopment and Research Cen-ter; David Bell, vice president ofthe Ford Foundation; and John J.Gillian, administrator of the USAgency for International Devel-opment, among others. The influ-ential McNamara was trying toovercome the criticism that theWorld Bank had ignored socialpoverty and the fatigue of donoragencies working in developingcountries. He promoted businessmanagement methods and clearsets of goals, and he moved theWorld Bank from supportinglarge growth projects aimed atgenerating economic growth toadvocating poverty reductionapproaches.31

The conference was based ona published paper by Julia Walshand Kenneth S. Warren entitled“Selective Primary Health Care,an Interim Strategy for DiseaseControl in Developing Coun-tries.”32 The paper sought spe-cific causes of death, paying spe-cial attention to the mostcommon diseases of infants indeveloping countries such as di-arrhea and diseases produced bylack of immunization. The au-thors did not openly criticize theAlma-Ata Declaration. They pre-sented an “interim” strategy orentry points through which basichealth services could be devel-oped. They also emphasized at-tainable goals and cost-effectiveplanning. In the paper, and atthe meeting, selective primaryhealth care was introduced asthe name of a new perspective.The term meant a package oflow-cost technical interventionsto tackle the main disease prob-lems of poor countries.

disapproval of the overspecializa-tion of health personnel in devel-oping countries and of top-downhealth campaigns. Instead, train-ing of lay health personnel andcommunity participation werestressed. In addition, the need forworking with traditional healerssuch as shamans and midwiveswas emphasized. Finally, the dec-laration linked health and devel-opment. Health work was per-ceived not as an isolated andshort-lived intervention but aspart of a process of improvingliving conditions. Primary healthcare was designed as the newcenter of the public health sys-tem. This required an intersector-ial approach—several public andprivate institutions working to-gether on health issues (e.g., onhealth education, adequate hous-ing, safe water, and basic sanita-tion). Moreover, the link betweenhealth and development had po-litical implications. According toMahler, health should be an in-strument for development andnot merely a byproduct of eco-nomic progress: “we could . . .become the avant garde of an in-ternational conscience for socialdevelopment.”27

The 32nd World Health As-sembly that took place inGeneva in 1979 endorsed theconference’s declaration. The as-sembly approved a resolutionstating that primary health carewas “the key to attaining an ac-ceptable level of health for all.”In the following years, Mahlerhimself became an advocate ofprimary health care, writing pa-pers and giving speeches withstrong titles such as “Health andJustice” (1978), “The PoliticalStruggle for Health” (1978),“The Meaning of Health for Allby the Year 2000” (1981), and“Eighteen Years to Go to Health


many health programs). Interest-ingly, acute respiratory infec-tions, a major cause of infantmortality in poor countries, werenot included. These werethought to require the adminis-tration of antibiotics that non-medical practitioners in many ofthe affected countries were notallowed to use.

Selective primary health careattracted the support of somedonors, scholars, and agencies.According to some experts, it cre-ated the right balance betweenscarcity and choice.36 One partic-ipant of the Bellagio meeting thatwas greatly influenced by thenew proposal was UNICEF.James Grant, a Harvard-trainedeconomist and lawyer, was ap-pointed executive director ofUNICEF in January 1980 andserved until January 1995.37

Under his dynamic leadership,UNICEF began to back awayfrom a holistic approach to pri-mary health care. The son of aRockefeller Foundation medicaldoctor who worked in China,Grant believed that internationalagencies had to do their bestwith finite resources and short-lived local political opportunities.This meant translating generalgoals into time-bound specific ac-tions. Like Mahler, he was acharismatic leader who had aneasy way with both heads ofstate and common people. A fewyears later, Grant organized aUNICEF book that proposed a“children’s revolution” and ex-plained the 4 inexpensive inter-ventions contained in GOBI.38

Mahler never directly con-fronted this different approachto primary health care. Aftersome doubts, Mahler himself at-tended the Bellagio Conference,and although there is evidencethat he did not get along with

the new director of UNICEF, heasked a WHO assistant directorto nourish a good relationshipbetween the 2 organizations.However, a debate between the2 versions on primary healthcare was inevitable.39 Some sup-porters of comprehensive pri-mary health care, as the holisticor original idea of primaryhealth care began to be called,considered selective primaryhealth care to be complemen-tary to the Alma-Ata Declara-tion, while others thought it con-tradicted the declaration. Somemembers of the WHO tried torespond to the accusation thatthey had no clear targets. For

example, a WHO paper entitled“Indicators for MonitoringProgress Towards Health for All”was prepared at the “urgent re-quest” of the Executive Board.40

Another publication providedspecific “Health for All” goals:5% of gross national product de-voted to health; more than 90%of newborn infants weighing2500 g; an infant mortality rateof less than 50 per 1000 livebirths; a life expectancy over 60years; local health care unitswith at least 20 essentialdrugs.41 However, most of thesupporters of primary healthcare avoided these indicators,


At first, the content of thepackage was not completelyclear. For example, in the originalpaper, a number of different in-terventions were recommended,including the administration ofantimalarial drugs for children(something that later disappearedfrom all proposals). However, inthe following years, these inter-ventions were reduced to 4 andwere best known as GOBI, whichstood for growth monitoring, oralrehydration techniques, breast-feeding, and immunization.

The first intervention, growthmonitoring of infants, aimed toidentify, at an early stage, chil-dren who were not growing asthey should. It was thought thatthe solution was proper nutri-tion. The second intervention,oral rehydration, sought to con-trol infant diarrheal diseaseswith ready-made packets knownas oral rehydration solutions.33

The third intervention empha-sized the protective, psychologi-cal, and nutritional value of giv-ing breastmilk alone to infantsfor the first 6 months of theirlives.34 Breastfeeding also wasconsidered a means for prolong-ing birth intervals. The final in-tervention, immunization, sup-ported vaccination, especially inearly childhood.35

These 4 interventions ap-peared easy to monitor and eval-uate. Moreover, they were meas-urable and had clear targets.Funding appeared easier to ob-tain because indicators of suc-cess and reporting could be pro-duced more rapidly. In the nextfew years, some agencies addedFFF (food supplementation, fe-male literacy, and family plan-ning) to the acronym GOBI, cre-ating GOBI-FFF (the educationallevel of young women and moth-ers being considered crucial to

“

”

Some supporters of comprehen-sive primary health care, as

the holistic or original idea of primary health care began to be

called, considered selective primary health care to be

complementary to the Alma-AtaDeclaration, while others thought it contradicted the declaration.



artificial infant formula were$2 billion a year (Third Worldnations accounted for 50% ofthe total).44 Companies argued—incorrectly—that infant formulashad to be used in developingcountries because undernour-ished mothers could not provideproper nourishment and pro-longed lactation would aggravatetheir health.45 In contrast, forhealth advocates, who launched aboycott against the Swiss multina-tional Nestlé, one of the mainproblems was the use of unsafewater for bottle-feeding in shanty-towns. This fascinating contro-versy helped to change maternalpractices in several countries butdid little to excite the enthusiasmof donor agencies.46

To supporters of comprehen-sive primary health care, oral re-hydration solutions were a Band-Aid in places where safe waterand sewage systems did not exist.However, this intervention, to-gether with immunization, be-came popular with agencies

working in developing coun-tries,47 partly thanks to an impor-tant achievement: the globaleradication of smallpox in 1980.Beginning in 1974, the WHO’sExpanded 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 infantsor “universal childhood immu-nization” by 1990. This programcontributed to the establishmentof cold-chain equipment, ade-quate sterilization practices, cele-bration of National VaccinationDays, and expanded systems ofsurveillance.48

Immunization campaigns ac-celerated in the developingworld after the mid-1980s. Theyalso gained the important sup-port of Rotary International.49

Colombia, for example, madeimmunization a national crusade.Starting in 1984, it was stronglysupported by the governmentand by hundreds of teachers,priests, policemen, journalists,and Red Cross volunteers.50 In1975, only 9% of Colombianchildren aged younger than 1year were covered with DPT (avaccine that protects againstdiphtheria, pertussis, andtetanus, given to childrenyounger than 7 years old). By1989, the figure had risen to75% and in 1990 to 87%.51 Ina corollary development, the in-fant mortality rate decreased.These experiences were instru-mental in overcoming popularmisperceptions such as that vac-cination had negative side ef-fects, was not necessary forhealthy children, and was notsafe for pregnant women.

However, the achievements ofimmunization did not lessen thedebate over primary health

arguing that they were unreli-able and failed to demonstratethe inequities inside poor coun-tries.42 The debate between the2 versions of primary healthcare continued.

THE DEBATE

The supporters of comprehen-sive primary health care accusedselective primary health care ofbeing a narrow technocentric ap-proach that diverted attentionaway from basic health and so-cioeconomic development, didnot address the social causes ofdisease, and resembled verticalprograms.43 In addition, criticssaid that growth monitoring wasdifficult since it required the useof charts by illiterate mothers(recording data was not an easyoperation, weighing scales werefrequently deficient, and chartswere subject to misinterpretation).Breastfeeding confronted power-ful food industries. In 1979, itwas estimated that global sales of

Oral rehydration salts pro-moted by selective primaryhealth care were criticized inthis drawing as a “Band-Aid.”(Drawing by Alicia Brelsford,reprinted with permission fromDavid Werner. David Wernerand David Sanders, with JasonWeston, Steve Babb, and BillRodriguez, Questioning theSolution: the Politics of PrimaryHealth Care and Child Survival,with an In-Depth Critique of OralRehydration Therapy [Palo Alto,CA : HealthWrights, 1997].)



care.52 Newell, one of the archi-tects of primary health care,made a harsh criticism: “[selec-tive primary health care] is athreat and can be thought of as acounter-revolution. Rather thanan alternative, it . . . can be de-structive. . . . Its attractions to theprofessionals and to fundingagencies and governments look-ing for short-term goals are veryapparent. It has to be rejected.”53

US agencies, the World Bank,and UNICEF began to prioritizesome aspects of GOBI, such asimmunization and oral rehydra-tion solutions. As a result, in-creasing tension and acrimonydeveloped between the WHOand UNICEF, the 2 founding in-stitutions of primary health care,during the early 1980s.54

The debate between these 2perspectives evolved around 3questions: What was the mean-ing of primary health care?How was primary health care tobe financed? How was it to beimplemented? The differentmeanings, especially of compre-hensive primary health care, un-dermined its power. In its moreradical version, primary healthcare was an adjunct to socialrevolution. For some, this wasundesirable, and Mahler was tobe blamed for transforming theWHO from a technical into apoliticized organization.55

For others, however, it wasnaïve to expect such changesfrom the conservative bureaucra-cies of developing countries. Ac-cording to their view, it was sim-plistic to assume that enlightenedexperts and bottom-up commu-nity health efforts had a revolu-tionary potential, and the politi-cal power of the rural poor wasunderestimated. They alsothought that the view of “com-munities” as single pyramidal

structures willing to participate inhealth programs after their lead-ers received the necessary infor-mation was idealistic. In fact,they said, these communities andtheir learning process were usu-ally diverse and complex.56

In its mildest version, primaryhealth care was an addition topreexisting medical services, afirst medical contact, an exten-sion of health services to ruralareas, or a package of selectiveprimary health care interven-tions. However, none of thesefeatures could avoid being con-sidered second-quality care, sim-plified technology, or poor healthcare for the poor.57 Two corol-lary criticisms from Latin Ameri-can leftist scholars were that “pri-mary” really meant “primitive”health care and that it was ameans of social control of thepoor, a debasement of the goldstandard established in Alma-Ata. A related question not an-swered was, Is primary healthcare cheaper than traditionalhealth interventions or does itdemand a greater investment?58

It was not clear just after theAlma-Ata meeting how primaryhealth care was going to be fi-nanced.59 In contrast to other in-ternational campaigns, such asthe global malaria eradicationprogram of the 1950s, whereUNICEF and US bilateral assis-tance provided funding, therewere no significant resources inthe WHO for training auxiliarypersonnel, improving nutritionand drinking water, or creatingnew health centers. It was diffi-cult to convince developingcountries to change their alreadycommitted health budgets. A1986 study examined several es-timates of primary health care indeveloping countries (aroundUS$1 billion) and concluded that

“the wide range of costs . . . is in-dicative of how little is knownabout this area.”60

As a result, most internationalagencies were interested in short-term technical programs withclear budgets rather than broadlydefined health programs.61 In ad-dition, during the 1980s manydeveloping countries confrontedinflation, recession, economic ad-justment policies, and suffocatingforeign debts that began to taketheir toll on public health re-sources. A new political contextcreated by the emergence of con-servative neo-liberal regimes inthe main industrialized countriesmeant drastic restrictions infunds for health care in develop-ing countries. According toMahler, during the 1980s, “Toomany countries, too many bilat-eral and multilateral agencies,too many individuals had be-come too disillusioned with theprospects for genuine humandevelopment.”62

The changing political contextwas also favorable for deeply in-grained conservative attitudesamong health professionals. Forexample, most Latin Americanphysicians were trained in med-ical schools that resembled USuniversities, were based in hospi-tals, lived in cities, received ahigh income by local standards,and belonged to the upper andupper-middle classes.63 They per-ceived primary health care asanti-intellectual, promotingpragmatic nonscientific solutionsand demanding too many self-sacrifices (few would considermoving to the rural areas orshantytowns). A minority of med-ical doctors who embraced pri-mary health care thought that itshould be conducted under theclose supervision of qualified pro-fessional personnel. Frequently,


they distrusted lay personnelworking as medical auxiliaries.

In a 1980 speech, Mahler hadalready complained about the“medical emperors” and theirnegativism toward primaryhealth care because of false“pompous grandeur.”64 The con-frontation made matters worse.The resistance of medical profes-sionals became more acute sincethey feared losing privileges,prestige, and power. Confronta-tion continued since there wasno steady effort to reorganizemedical education around pri-mary health care or to enhancethe prestige of lay personnel.However, for a generation ofLatin American medical students,primary health care became anintroduction to public health andMahler a sort of icon.

Another problem of primaryhealth care implementation wasreal political commitment. SomeLatin American authoritarianregimes, such as the militaryregime in Argentina, formally en-dorsed the Alma-Ata Declarationbut did not implement any tangi-ble reform. Because most inter-national agencies favored selec-tive primary health care, manyLatin American ministries ofhealth created an underfundedprimary health care program intheir fragmented structures andconcentrated on 1 or 2 of theGOBI interventions. As a re-sult, the tension between thosewho advocated vertical, disease-oriented programs and thosewho advocated community-oriented programs was acceptedas a normal state of affairs.

During the mid-1980s,Mahler continued his crusade fora more holistic primary healthcare in different forums. How-ever, he was frequently alone,since he did not have the full

support of the WHO’s bureau-cracy, and his allies outsideWHO were not always available.For example, from 1984 to1987, an important US scholarfor primary health care, CarlTaylor, left Johns Hopkins andwas a UNICEF representative inChina. In 1985, Tejada-de-Rivero,one of Mahler’s main assistantsat Geneva, moved permanentlyto Peru, where he became minis-ter of health. In 1988, Mahlerended a 3-term period as direc-tor general of the WHO. Al-though he never officiallylaunched a reelection campaign,no one appeared who was sec-ond-in-command or had suffi-cient energy to keep promotingprimary health care against allodds. In a confusing election andan unexpected turn of events,the Japanese physician HiroshiNakajima was elected as the newdirector general.

Nakajima lacked the commu-nication skills and charismaticpersonality of his predecessor.His election can be considered tomark the end of the first periodof primary health care. TheWHO seemed to trim primaryhealth care, and most impor-tantly, the WHO lost its politicalprofile. In a corollary develop-ment, a 1997 Pan AmericanHealth Organization documentproposed a new target, or a newdeadline, entitled “Health for Allin the 21st Century.”65 Support-ers of a holistic primary healthcare believed that the originalproposal largely remained on thedrawing board,66 a claim stillmade today.

CONCLUSION

The history of the origins ofprimary health care and selectiveprimary health care analyzed in

this article illustrate 2 diverse as-sumptions in international healthin the 20th century. First, therewas a recognition that diseases inless-developed nations were so-cially and economically sustainedand needed a political response.Second, there was an assumptionthat the main diseases in poorcountries were a natural realitythat needed adequate technologi-cal solutions. These 2 ideas weretaken—even before primaryhealth care—as representing adilemma, and one path or theother had to be chosen.

I have illustrated the crucialinteraction between the context,the actors, the targets, and thetechniques in internationalhealth. Primary health care andselective primary health care rep-resent different arrangements ofthese 4 factors. In the case of pri-mary health care, the combina-tion can be summarized as thecrisis of the Cold War, the promi-nence of Mahler at the WHO,the utopian goal of “Health forAll,” and an unspecific method-ology. The combination in thecase of selective primary healthcare was neo-liberalism, theleadership of Grant as head ofUNICEF, the more modest goalof a “children’s revolution,” andGOBI interventions.

A lesson of this story is thatthe divorce between goals andtechniques and the lack of articu-lation between different aspectsof health work need to be ad-dressed. A holistic approach, ide-alism, technical expertise, and fi-nance should—must—go together.There are still problems of terri-toriality, lack of flexibility, andfragmentation in internationalagencies and health programs indeveloping countries. Primaryand vertical programs coexist.One way to enhance the integra-

tion of sound technical interven-tions, socioeconomic develop-ment programs, and the trainingof human resources for health isthe study of history.

About the AuthorThe author is with the Department ofSociomedical Sciences, School of PublicHealth, Universidad Peruana CayetanoHeredia, Lima, Peru.

Requests for reprints should be sent toMarcos Cueto, PhD, Roca Bologna 633,Lima 18, Peru (e-mail: [email protected]).

This article was accepted March 13,2004.

AcknowledgmentsResearch for this article was made possi-ble thanks to the Council for Interna-tional Exchange of Scholars–FulbrightNew Century Scholars Program “Chal-lenges of Health in a Borderless World”and the Joint Learning Initiative forHuman Resources for Health and Devel-opment. The article was completed dur-ing 2004 when the author was a visit-ing fellow at the Woodrow WilsonCenter in Washington, DC.

Endnotes 1. S. Litsios, “The Long and DifficultRoad to Alma-Ata: A Personal Reflec-tion,” International Journal of Health Ser-vices 32 (2002): 709–732; S. Lee,“WHO and the Developing World: TheContext for Ideology,” in Western Medi-cine as Contested Knowledge, ed. A. Cun-ningham and B. Andrews (Manchester:Manchester University Press, 1997),24–45.

2. J. H. Bryant, Health and the Devel-oping World (Ithaca, NY: Cornell Uni-versity Press, 1969), ix–x.

3. C. E. Taylor, ed., Doctors for theVillages: Study of Rural Internships inSeven Indian Medical Colleges (NewYork: Asia Publishing House, 1976).

4. K. W. Newell, Health by the People(Geneva: World Health Organization[WHO], 1975), xi.

5. Canadian Department of NationalHealth and Welfare, A New Perspectiveon the Health of Canadians/Nouvelle per-spective de la sante des Canadiens (Ot-tawa: n. p., 1974).

6. T. McKeown, The Modern Rise ofPopulation (New York: Academic Press,1976).

7. I. Illich, Medical Nemesis: the Expro-priation of Health (London: Calder &Boyars, 1975).



8. G. Paterson, “The CMC Story,1968–1998,” Contact 161–162 (1998):3–18.

9. R. Martin, “Christians Pioneer In-ternational Health Concepts,” availableat http://www.ccih.org/forum/0011-03.htm, accessed March 19, 2004.

10. V. W. Sidel, “The Barefoot Doctorsof the People’s Republic of China,” NewEngland Journal of Medicine 286(1972): 1292–1300. See also R. Sideland V. Sidel, Health Care and TraditionalMedicine in China, 1800–1982 (Lon-don: Routledge and Kegan, 1982).

11. L. B. Pearson, Partners in Develop-ment (New York: Praeger, 1969); W.Brandt, North–South, A Program for Sur-vival (Cambridge, Mass: MIT Press,1980).

12. L. A. Hoskins, “The New Interna-tional Economic Order: A BibliographicEssay,” Third World Quarterly 3 (1981):506–527.

13. The biographical information istaken from “Dr Halfdan T. Mahler,”available at http://www.who.int/archives/wh050/en/directors.htm, accessed March 19, 2004.

14. H. T. Mahler, interview with theauthor, Geneva, May 2002.

15. Mac McGivray (a CMC member)after a meeting with Mahler on March22, 1974. Cited in Paterson, “The CMCStory,” 13.

16. V. Djukanovic and E. P. Mach, eds.,Alternative Approaches to Meeting BasicHealth Needs of Populations in Develop-ing Countries: A Joint UNICEF/WHOStudy (Geneva: WHO, 1975), 110.

17. “The Work of WHO in 1972: An-nual Report of the Director General tothe World Health Assembly,” in WHOOfficial Records 205, 1973, Geneva,WHO Library.

18. Djukanovic and Mach, AlternativeApproaches, 14.

19. H. T. Mahler, “Social Perspectivesin Health: Address in Presenting His Re-port for 1975 to the Twenty-NinthWorld Health Assembly, Geneva, 4May 1976,” 1, Mahler Speeches/Lec-tures, Box 1, WHO Library.

20. “Interview with David Tejada-de-Rivero,” in World Federation of PublicHealth Associations, Conference Bulletin 1(1977): 1, Folder “WHO InternationalConference on Primary Health Care1978, November 1977–January 1978,”P/21/87/5, WHO Archive, Geneva.

21. D. D. Venediktov, “Primary HealthCare: Lessons From Alma Ata,” WorldHealth Forum 2 (1981): 332–340,quote from p. 333.

22. “United Nations Economic and So-

cial Council, United Nations Children’sFund, Executive Board, 29 October1976,” Folder “WHO International Con-ference on Primary Health Care 1978,August 1975–February 1977,”P/21/87/5, WHO Archive.

23. Tejada-de-Rivero had great care forthe details of organizing the meeting,shown in his request for “250 desksand tables, 500 chairs, 200 typistdesks, 200 typist chairs,” among otheritems; D. Tejada-de-Rivero to D.Venediktov, September 20, 1976,Folder “WHO International Conferenceon Primary Health Care 1978 August1975–February 1977,” P 21/87/5.WHO Archive.

24. “Intervention of Director Generalof WHO, H. Mahler,” in “Alma Ata1978, International Conference on Pri-mary Health Care, 6–12 September1978, Statements by Participants in thePlenary Meetings,” 4–6, ICPHC/ALA/78.1-11, WHO Library, Geneva.

25. See H. T. Mahler, “Health—A De-mystification of Medical Technology,”Lancet ii (1975): 829–833.

26. H. T. Mahler, World Health IsIndivisible: Address to the Thirty-FirstWorld Health Assembly (Geneva:WHO, 1978), 4.

27. H. T. Mahler, “WHO’s Mission Re-visited: Address in Presenting His Re-port for 1974 to the 28th World HealthAssembly, 15 May 1975,” 10, MahlerSpeeches/Lectures, Box 1, WHO Li-brary, Geneva.

28. “WHA32.30, Formulating Strate-gies for Health for all by the Year2000, World Health Organization,32nd World Health Assembly, Geneva,7–25 May 1979,” available at http://policy.who.int/cgi-bin/ om_isapi.dll?infobase=WHA&softpage=Browse_Frame_Pg42, accessed June 25, 2004; H.T. Mahler, “Salud con Justicia,” SaludMundial (May 1978); “What Is Healthfor All?” World Health (November1979): 3–5; Mahler, “The Meaning ofHealth for All by the Year 2000,”World Health Forum 2 (1981): 5–22;Mahler, “The Political Struggle forHealth: Address at the 29th Session ofWHO Regional Committee for theWestern Pacific”; Mahler, “EighteenYears to Go to Health for All, Addressto the 21st Pan American Sanitary Con-ference, Geneva” (all Mahler articlesfrom Mahler Speeches/Lectures, Box 1,WHO Library, Geneva).

29. K. Kanagaratnam, “A Review ofthe Bellagio Population and Health Pa-pers,” May 9, 1979, Folder “Health andPopulation,” Rockefeller FoundationArchives (hereafter RFA), Record Group(hereafter RG) A82, Series 120, Box

1776, Rockefeller Archive Center,Sleepy Hollow, NY (hereafter RAC).

30. J. H. Knowles, ed., Doing Better andFeeling Worse (New York: W.W. Nortonand Co., 1977).

31. J. H. Knowles to C. Wahren, July 6,1978, Folder “Health and Population,”RFA, RG A82, Series 120, Box 1776,RAC; Martha Finnemore, “RedefiningDevelopment at the World Bank,” in In-ternational Development and the SocialScience: Essays in the History and Politicsof Knowledge, ed. F. Cooper and R.Packard (Berkeley: University of Califor-nia Press, 1997), 203–227.

32. J. A. Walsh and K. S. Warren, “Se-lective Primary Health Care, an InterimStrategy for Disease Control in Develop-ing Countries,” New England Journal ofMedicine 301 (1979): 967–974; it alsoappeared in Social Science and Medicine14C (1980): 145–163 as part of anissue devoted to the Bellagio meeting.

33. J. Ruxin, “Magical Bullet: The His-tory of Oral Rehydration Therapy,”Medical History 38 (1991): 363–397.

34. S. Plank and M.L. Milanesi, “InfantFeeding and Infant Mortality in RuralChile,” Bulletin of the World Health Or-ganization 48 (1973): 203–210.

35. Protecting the World’s Children:Vaccines and Immunization Within Pri-mary Health Care, Conference Report(New York: Rockefeller Foundation,1984).

36. J. Evans, K. Hall, and J. Warford,“Health Care in the Developing World:Problems of Scarcity and Choice,” NewEngland Journal of Medicine 305(1981): 1117–1127.

37. On Grant, see C. Bellamy, P.Adamson, S. B. Tacon, et al., Jim Grant:UNICEF Visionary (Florence, Italy:UNICEF Innocenti Research Center,2001), available at http://www.unicef.org/ about/who/index_bio_grant.html,accessed March 19, 2004.

38. UNICEF, The State of the World’sChildren: 1982/1983 (New York: Ox-ford University Press, 1983). See also K.S. Warren, “Introduction,” in Strategiesfor Primary Health Care: TechnologiesAppropriate for the Control of Disease inthe Developing World, ed. J. Walsh andK. S. Warren (Chicago: University ofChicago, 1986), ix–xi; K. S. Warren,“The Evolution of Selective PrimaryHealth Care,” Social Science and Medi-cine 26 (1988): 891–898.

39. Examples of the debate are the let-ters sent to the editor that appeared inthe “Correspondence” section of the NewEngland Journal of Medicine 302 (1980):757–759. See also S. Rifkin and G.Walt, “Why Health Improves: Defining

the Issues Concerning ‘ComprehensivePrimary Health Care’ and ‘Selective Pri-mary Health Care,’ ” Social Science andMedicine 23 (1986): 559–566; J. P.Unger and J. Killingsworth, “Selective Pri-mary Health Care: A Critical Review ofMethods and Results,” Social Science andMedicine 10 (1986): 1001–1002; thespecial issue “Selective or Comprehen-sive Primary Health Care” of Social Sci-ence and Medicine 26(9) (1988).

40. “WHO Indicators for MonitoringProgress Towards Health for All: Discus-sion Paper, Geneva March 17, 1980,”HPC/MPP/DPE/80.2, WHO Library,Geneva.

41. “Primary Health: A First Assess-ment,” People Report on Primary HealthCare (1985): 6–9, WHO Library,Geneva.

42. Venediktov, “Lessons,” 336.

43. O. Gish, “Selective Primary Care:Old Wine in New Bottles,” Social Sci-ence and Medicine 16 (1982): 1054.

44. J. E. Post [associate professor ofmanagement policy at Boston UniversitySchool of Management] to R. Bartley[editor of the Wall Street Journal], No-vember 13, 1979, Folder “The Protec-tion and Promotion of Breast Feeding,”CF-NYH-09 D 5-81 Heyward T011 A138, UNICEF Archives, New York, NY.

45. H. I. Sheefild, “Boycott to SaveLives of Third World Babies,” MichiganChronicle, December 29, 1979 [newspa-per clipping], Folder “The Protectionand Promotion of Breastfeeding,” CF-NYH-09 D 05-81 Heyward T011A138, UNICEF Archives.

46. “Criticism Mounts Over Use ofBaby Formulas Among World’s Poor,”Washington Post, April 21, 1981 [news-paper clipping], Folder “The Protectionand Promotion of breastfeeding,” CF-NYH-09 D 05-81 Heyward T011A138, UNICEF Archives; J. E. Post andE. Baer, “The International Code ofMarketing for Breast Milk Substitutes:Consensus, Compromise and Conflictin the Infant Formula Controversy,”The Review: International Commissionof Jurists 25 (December 1980):52–61; M. B. Bader, “Breast-Feeding:The Role of the Multinational Corpora-tions in Latin America,” InternationalJournal of Health Services 6 (1976):604–626.

47. During these years, most develop-ing countries significantly improved thecoverage figures. “Expanded Pro-gramme on Immunization, November24, 1978,” Folder “WHO-UNICEF JointStudy,” CF-NYH-09 D Heyward T010A128, UNICEF Archives.

48. T. Hill, R. Kim-Farley, and J.



Rohde, “Expanded Programme on Im-munization: A Goal Achieved TowardsHealth for All,” in Reaching Health ForAll, ed. J. Rohde, M. Chatterjee, and D.Morley (Delhi: Oxford University Press,1993), 403–422.

49. G. Nossal, “Protecting Our Prog-eny: The Future of Vaccines,” Perspec-tives in Health Magazine 7 (2002):8–13.

50. UNICEF, UNICEF in the Americas,for the Children of Three Decades,UNICEF, History Series 85, MonographIV, 1995, UNICEF Library, New YorkCity.

51. F. Muller, “Participation, Povertyand Violence: Health and Survival inLatin America,” in Reaching Health forAll, 103–129.

52. There were even radical critiquesof the original Alma Ata Declaration,such as V. Navarro, “A Critique of theIdeological and Political Positions of theWilly Brandt Report and the WHOAlma Ata Declaration” [1984], in V.Navarro, Crisis, Health and Medicine: ASocial Critique (London: Tavistock Publi-cations, 1986), 212–232.

53. K. W. Newell, “Selective PrimaryHealth Care: The Counter Revolution,”Social Science and Medicine 26 (1988):903–906, quote from p. 906.

54. J. Goodfield, A Chance to Live (NewYork: McMillan International, 1991),25–42.

55. Mahler himself mentions it in H. T.Mahler, “The Political Struggle forHealth: Address of the Director Generalat the 29th Session of the RegionalCommittee for the Western Pacific,Manila, August 21, 1978,” MahlerSpeeches/Lectures, Box 1, WHO Li-brary, Geneva.

56. A. W. Parker, J. M. Walsh, and M. A. Coon, “Normative Approach tothe Definition of Primary Health Care,”Milbank Memorial Fund Quarterly 54(1976): 415–438.

57. See J. Frenk, “First Contact, Simpli-fied Technology or Risk Anticipation?Defining Primary Health Care,” Acade-mic Medicine 65 (1990): 676–679.

58. See J. Breilh, “Community Medi-cine Under Imperialism: A New MedicalPolice,” International Journal of HealthServices 9 (1979): 5–24; M. Testa,¿Atención Primaria o primitiva? DeSalud,” in Segundas Jornadas de AtenciónPrimaria de la Salud (Buenos Aires: Aso-ciación de Médicos Residentes del Hos-pital de Niños Ricardo Gutiérrez, 1988),75–90; A. Ugalde, “Ideological Dimen-sions of Community Participation inLatin American Health Programs,” So-cial Science and Medicine 21 (1985):41–53.

59. The concern appears in someUNICEF documents, such as “Memo-randum From F. L. Fazzi, December22,1977 Un-edited Redraft on Budget-ing of [Primary Health Care],” Folder“WHO and UNICEF Fund Raising,” CF-NYH-09 D, UNICEF Archives.

60. M. Patel, “An Economic Evaluationof Health For All,” Health and Policy andPlanning 1 (1986): 37–47.

61. S. B. Rifkin, F. Muller, and V. Bich-mann, “Primary Health Care: On Mea-suring Participation,” Social Science andMedicine 26 (1988): 931–940.

62. H. T. Mahler, “World Health 2000and Beyond: Address to the 41st WorldHealth Assembly 3 May 1984,” MahlerSpeeches/Lectures, Box 1, WHO Li-brary.

63. A. J. Rubel, “The Role of Social Sci-ence Research in Recent Health Pro-grams in Latin America,” Latin Ameri-can Research Review 2 (1966): 37–56.

64. H. T. Mahler, Primary Health Care,an Analysis of Some Constraints, an Ad-dress Delivered to the Special Congrega-tion for the Conferment of an HonoraryDegree on Dr. Halfan T. Mahler at theUniversity of Lagos (Lagos: University ofLagos Press, 1980), 10, MahlerSpeeches/Lectures, Box 1, WHO Li-brary, Geneva.

65. Pan American Health Organiza-tion, Salud para Todos en el Siglo Veinti-nuno (Washington, DC: PAHO, 1997).

66. D. Werner and D. Sanders, Ques-tioning the Solution: The Politics of Pri-mary Health Care and Child Survival,With an In-Depth Critique of Oral Rehy-dration Therapy (Palo Alto, Calif: HealthRights, 1997). See also “Round Table:[Primary Health Care]—What StillNeeds to Be Done?” World HealthForum 11 (1990): 359–366.


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