This year marks the 40th anniversary of the Alma-Ata Declaration, a landmark global health policy document that reinforced health as a fundamental human right and emphasized that gross health inequalities are by no means acceptable. It also prescribed primary health care (PHC) founded on essential health services and community participation as a vital strategy towards achieving ‘Health for All’ by year 2000.
In 2018, we still do not have health for all. While significant progress has been achieved throughout the decades, from increasing life expectancy to dramatic reductions in child and maternal mortality, new global health problems have since emerged. Chronic diseases such as diabetes and cancer are on the rise, now killing more people than infectious diseases. The 2013 Ebola outbreak triggered efforts to solidify global health security worldwide. And although many states are preoccupied with achieving universal health coverage, scandalous levels of health inequality continue to exist between and within countries.
Climate change – our biggest threat
But on top of all these global health problems is climate change, the defining challenge of our time. When Alma-Ata was adopted in 1978, climate change was only beginning to be recognized by scientists—today, it is dubbed the 21st century’s biggest global health threat. From disability and death due to natural disasters, and climate migration due to sea level rise, to slow-onset increases in mosquito-borne diseases, heat-related illnesses and worsening undernutrition, climate change will cause additional stress to already overburdened health systems, reverse the health gains of PHC, and make the fulfillment of ‘Health for All’ much more difficult, if not impossible.
Unfortunately, in global health we do not say it as much as we should—that climate change is the biggest threat to PHC, to our universal health coverage goal, and to the sustainability of health systems worldwide. The way PHC is discussed today—as indicated in recent journal series and conferences commemorating Alma-Ata’s 40th anniversary, such as the one happening this week in Astana—is as if health systems and communities are totally detached from the climate reality we live in. Thankfully, the just-adopted Astana Declaration acknowledges “climate change and extreme weather events” as causing an additional public health burden today.
Since this climate reality is inescapable, the global health community has no other recourse but to embrace it. The vision for ‘Health for All’ must be rewritten, and it must be extended beyond the health of people to the health of the planet. Since human health and the environment are tightly intertwined and inseparable, the new approach to health improvement worldwide must encompass both. In short, a revitalized PHC—Alma-Ata 2.0—must now stand for ‘Planetary Health Care’.
Health and ecology on a planetary scale
This is not to say that PHC as a philosophy of health system organization and population health management should be abandoned. In fact, with the myriad global environmental challenges that are shaping future human health today, PHC has become much more relevant than ever before. Responsive and adaptive health systems rooted in strong communities and intersectoral action are the foundation for health protection, especially in a world of climate instability.
Even in 1978, Alma-Ata called for tackling the broader determinants of health and health inequalities. Now the era of planetary health presents a great opportunity to revitalize this often-neglected aspect, and integrate the care for the human family with the management of the planetary household. The 1978 declaration included “promotion of food supply and proper nutrition” and “adequate supply of safe water and basic sanitation” as essential PHC services. Moreover, the health sector is urged to collaborate with agencies that focus on ecological determinants such as ‘agriculture, animal husbandry, food’ among others, as part of the broader PHC strategy that, unfortunately, is frequently overlooked.
Climate change impacts, and other forms of environmental destruction such as biodiversity loss, land use change, rapid urbanization, and ocean acidification, are now the new environmental drivers of population health change. This requires a new, expansive way of thinking and arena for action. Alma-Ata 2.0 must push not just for improved sanitation locally, as was the case for PHC, but for ecological integrity on a regional and even global scale. This means complementing community-based interventions for hygiene, sanitation, and disease control with ecosystem-level approaches for environmental conservation, restoration, and transformation.
New International Economic Order 2.0? The Doughnut Economy
Like the original vision of ‘Health for All’ through PHC, this new vision of Planetary Health Care cannot succeed without the necessary transformations in the global economic system. With the Cold War in the background, Alma-Ata supported the creation of a New International Economic Order, as an alternative to the unfair Bretton Woods system that constrained the social and economic development of many developing countries.
The Cold War may have long ended, but a new battle has emerged—the fight against what scientists call a Hothouse Earth—an uncontrollable and irreversible state of extreme warming that poses catastrophic impacts on both human and planetary survival. Recent pronouncements from the United Nations Secretary-General and the UN Intergovernmental Panel on Climate Change have warned about this bleak scenario and called for fast and urgent action to avoid the tipping point.
For decades, the call for a New International Economic Order has largely been ignored, even by those who claim to espouse PHC principles. To this day, the neoliberal economic regime still obstructs the path to ‘Health for All’.
But with the climate clock ticking and the point of no return becoming ever closer and non-negotiable, the construction of a new economic order cannot be further delayed. I believe there is one proposal that stands out which offers the best chance for survival—the “Doughnut Economy,” conceptualized by Oxford economist Kate Raworth. Challenging the conventional economic thinking of limitless GDP growth, she laments: “Today, we have economies that need to grow, whether or not they make us thrive; what we need are economies that make us thrive, whether or not they grow.”
In her proposed framework, Raworth redraws the economy not in terms of endless supply and demand curves, but in the shape of a doughnut, which she regards as the “ecologically safe and socially just space for humanity.” She argues that the goal of the economy in the 21st century must be to meet people’s needs without breaching planetary limits. This necessitates no shortfalls in the inner social foundation—which includes health, education, gender equality, and political voice, among others—and no overshooting the ecological ceiling—which covers climate change, biogeochemical cycles, and biodiversity.
Power and human rights activism in Alma-Ata 2.0
This perhaps is the healthiest doughnut that the global health sector will be ever prescribing in the name of Planetary Health Care. But transforming the economy necessitates a rearrangement of power in society. Rather than people having the power to demand their right to health, too often access to PHC is determined by neo-liberal or corrupt governments, self-interested donors, a profiteering private sector, environmental polluters, men who do not understand women’s experiences—in short, actors that block the way towards a Doughnut Economy. Now that Planetary Health Care seeks to address the combined environmental and health crises we are in today, there is no better time to re-interrogate and challenge these power structures that fail to promote health, harm the planet, and perpetuate injustice, and let the people reclaim their power.
Planetary Health Care and the Doughnut Economy must be pushed by a strong social movement guided by the principles of human rights, which are at the very heart of Alma-Ata. The original declaration reaffirmed that health is a fundamental human right that must be enjoyed by all people. In the 21st century, with global environmental change in the background, there is no doubt that this basic right encompasses not just healthcare, but a healthful ecology that is vital for health, wellbeing, and dignity.
Planetary Health Care therefore opens a new opportunity for whole-of-society activism for human rights. Health advocates must intensify their partnership and solidarity with other human rights activists, including environmental rights activists who are now being killed in record numbers globally. This revitalized and expanded Alma-Ata 2.0 will unify a much broader range of advocates and actors, including the millennial generation who are hugely dissatisfied with the status quo. This powerful new vision has fresh energy and ambition, and provides a renewed sense of hope.
Undoubtedly, PHC will continue to endure to achieve global health equity. But Alma-Ata 2.0, founded on Planetary Health Care, will ensure the survival of the human civilization and its harmonious co-existence with Planet Earth.
Renzo Guinto (@RenzoGuinto) is a Filipino physician working to energize the emerging field of planetary health. A Doctor of Public Health candidate at Harvard and the sole student member of the Editorial Advisory Board of The Lancet Planetary Health, Renzo is currently establishing PH Lab, a “glocal think-and-do tank” for generating innovative solutions for Philippine health, public health, and planetary health. In 2008, Renzo was a youth delegate to the 30th anniversary conference of the Alma-Ata Declaration, and this year, he returned to the 40th anniversary conference in Astana to inspire a new generation of primary health care leaders.