PHC vs. sPHC and what will I do with my life?

My life in the past couple of weeks has changed radically. The training course that I rarely wrote about is done and I have learned a great deal about this place. Right now my life consists of going to villages with the mobile health team, studying Marathi, and reading about primary health care and mental health. I am figuring out what I will be doing in the next couple of months and right now I am interested in helping to develop a mental health program of some sort. More on that later.

I have also been reflecting a lot on my understanding of health, health work, and this organization. CRHP is quite an important place in the history of international health and provides a very successful and particular view of what one can do and what is possible. In reading about this place and the history of health I am forming my own thoughts on what I can do in my life as a doctor. To explain where I am now let me give you a little bit of history about this place and about international health. It’s really amazing to read about the discussions of health and be sitting in an organization that was key in creating a dream.

Some historical context and the creation of the dream:
In the 1940s during WWII a lot of new antibiotics and other medicines came out that drastically improved doctors' ability to treat diseases. These medicines were not cheap, however, and in the 1950s and 60s many international health NGOs ran into financial difficulties as they were trying to improve the health of their populations. The Christian Medical Council in Geneva, a worldwide collection of many different major health NGOs, decided to examine different health models to see how they could more cheaply and effectively improve health. They came here, to Jamkhed, and were moved by the model and how one could bring health to the poor by not focusing on medicines but instead on poverty, casteism, and patriarchy. Their close connections to the WHO meant that instantly Jamkhed was on the world map, and a major health official visited here and wrote a book, Health by the People, that explored different case studies (including Jamkhed) and argued for the possibility of providing health for all in the world. The book came out in 1975, and in 1978 the countries of the world came together in Alma Ata, Soviet Kazakhstan, to declare their commitment to bring health to all via Primary Health Care by 2000. In other words, the entire world had signed on to a commitment to switching the focus of their health care to improving the health of their rural poor by working on development issues, disseminating health information, decentralizing health work, and battling marginalization and discrimination. This organization played an important role in creating that dream.

The debate:
The next year, in a huge twist of events, the Rockefeller foundation hosted a meeting to discuss what to do. It was felt that these goals were a little bit idealistic and unrealistic. They took some of the ideas and came up with a new program, called selective-PHC (or sPHC) that would take some of the initiatives found in PHC programs around the world and provide the funding for them. These programs were known as GOBI-FFF, for Growth monitoring, Oral rehydration treatment, Breastfeeding, Immunization, Female literacy, Family planning, and Food supplementation. A huge debate was started. PHC people accused sPHC of being a vertical program and not doing enough to change the society, and sPHC people asked the PHC what exactly PHC meant, how to operationalize it, measure it, and fund it.

Two views on disease causation:
A recent article breaks down the debate to different positions about disease causation: either one believes chiefly that diseases are socially and economically sustained and need political solutions or one believes that diseases are a natural reality that requires adequate technological solutions. PHC believes in the former and argues that if people are to be healthy there has to be a revolution in the way people interact with each other. Pointing to examples around the world, from Jamkhed and other similar NGOs to China and Cuba, they say that it is not only possible but the ONLY way to achieve adequate health for all. sPHC takes the latter position and says that while we figure out how to treat each other better there are many different programs, ideas, and medicines that could be extended to the very poor and make a huge difference in their lives right now. In this view they focus on the “natural” reality of diseases coming up and seek to implement GOBI-FFF to create better health.

A further distinction:
I think I could break this down to another distinction: idealism vs. pragmatism. The promoters of PHC at Alma Ata had visited case studies around the world and seen the reality of what is possible when committed doctors, health workers, and health ministers work to battle the social and economic determinants of health. They then asked the entire world, with all of its divisions and entrenched interests, to unite behind PHC and to change social and economic realities for the purpose of health. When it didn’t work out they became very frustrated and blamed self-interested institutions, bloated bureaucracies, and selfishness. sPHC on the other hand, tried to work with the reality that existed in terms of how funding is done and health care delivered to move in the direction of PHC. They worked with the world as it was but tried to make it better. The question is how committed are they to PHC and how much change do they really bring?

My thoughts:
I am fascinated by this debate. I think I understand both positions and feel emotionally connected to both positions, but in different ways. I agree with PHC that the primary cause of disease is economic and social marginalization. Of course anyone, no matter how privileged their lives, can come down with any illness. Recent events close to me have particularly shown this reality. Yet at the same time my experiences abroad have shown me the reality of the vast inequalities in health outcomes across the world and driven deep my comprehension of structural violence: that the diseases and suffering in this world are not produced just randomly or by chance by “natural causes” but instead largely determined by social and economic structures and therefore are distributed in a heavily skewed manner to the lowers of the world. In other words, the reality of microbes invading our body and our bodies breaking down interacts heavily with axes of power such as wealth, class, race, caste, gender, geography, nationality, ethnicity, sexuality, etc. to make it so that the lowers are the most likely to have ill health.
At the same time, I also am in sPHC’s position of believing it incredibly naïve of the PHC people to think that people around the world would change their ways for the sake of health. Why would we treat each other better, work for land reform, focus on the poor, and not discriminate against each other because doing so would give everyone a healthy and productive life?

I have this view when I look at CRHP and the possibility of scaling up PHC for everyone. I know deeply that PHC is possible and successful – I am seeing it and experiencing it everyday. CRHP was able to reduce casteism's and patriarchy’s power and create great health for the population. But they also had two incredibly intelligent, dedicated, self-sacrificing, and self-developed doctors devoted to the cause. How can we expect to scale up such inner development, morality, and virtue?
Other large scale versions of PHC, such as China and Cuba, certainly bettered health, but at what cost? Is ideology the alternative to morality? Does large-scale battling of the social determinants of health require ideological revolution? Considering the bloody history of ideological revolutions and the fall of communism, what is the alternative?

I don’t have any real thoughts on what that might look like. PHC, as a worldwide reality, has not materialized. The WHO keeps on renewing its commitment yet very little changes. People talk about keeping the dream alive, rather than achieving it.

I am similarly unsure about myself. I am actually feeling myself to be more of a pragmatist nowadays. I think earlier I was more idealistic – I would have become angry at the failure of PHC and blamed the powerful and privileged. I now fully recognize myself as one of those powerful and privileged and, feeling personally how difficult life can be for everyone, see how difficult it is to move beyond one’s self-interests to work substantively for principles such as equity, justice, and health for all. I am navigating the balancing of taking care of myself and finding my own happiness with what I feel is a future as a global physician who, if he wants to actually achieve health for all, has to battle the very difficult social and economic determinants of health.