Understanding the politics of child health care with David Sanders – Peoples Dispatch

David Sanders (1944 – 2019) was one of the founding members of the People’s Health Movement in Savar, Bangladesh, in 2000. A pediatrician by training, Sanders was a passionate advocate of Health for All and Comprehensive Primary Health Care. His expertise in child health and nutrition, human resources for health, and health systems development was an invaluable contribution to many discussions in the field of global health. Over the course of his academic and activist work, David encouraged and inspired new generations of health activists to continue the struggle for the right to health.

In a podcast published by Anthony Costello from The Social Edge (2018), Sanders talked about his health activism, the politics of child health, and key venues of work of young health activists. In the lead-up to World Breastfeeding Week 2023, we look back at some of David’s reflections in an interview originally published on The Social Edge.

Anthony Costello (AC): The Declaration of Alma Ata took place in 1978, and Zimbabwe gained independence in 1980. When you returned to Zimbabwe during that time, you were filled with great optimism. However, things had changed significantly by the late 80s when we first met, and throughout the early 90s. This transformation was a result of the Thatcher-Reagan era coming into power, with the dominance of neoliberal economic principles and a massive debt crisis in developing countries. In response to this crisis, the World Bank and IMF promoted structural adjustment, aiming to boost the market and increase prices, adopting a free-market approach. Many people were already expressing concern that these changes were having a devastating effect on the poor.

I recall a conversation we had where you pointed out that while HIV in Africa was rightfully receiving attention, the health impacts of structural adjustment were being overlooked. This insight greatly inspired me, as it made me wonder how we should address this issue. You were the only person I felt was delving into the root causes of child ill health. Consequently, I teamed up with economist David Woodward, and together we wrote “Human Face or Human Façade?” in response to UNICEF’s approach of adjusting with a human face.

Now, looking at the present situation, we have experienced another 20 or 30 years of continuing free-market, neoliberal economics, accompanied by a massive financial crisis. This raises the question: what are the politics of child health, considering the causes of the causes? Some individuals, such as Bill Gates and Hans Rosling, argue that everything is improving and mortality rates are falling. However, we need to take a closer look. Data from Brazil, for instance, shows that stunting rates are actually increasing in some countries, while the gap between the rich and poor has narrowed in some places and widened in others. The situation is complex, and it requires a nuanced analysis. In light of this, I am curious to know your perspective on the current state of affairs and the underlying causes affecting child health. How do you see these issues now?

David Sanders (DS): In the 70s, there were contending ideologies: capitalism and socialism. Additionally, social democracy, which was being practiced in numerous countries, including the UK, represented a middle ground. However, today, there seems to be only one dominant ideology influencing public health and child health work. Unfortunately, very little attention is given to what we, in the People’s Health Movement and indeed in scholarly writing, believe are the fundamental pillars of Primary Health Care. These pillars include community participation, inter-sectoral action, appropriate technology, equity, and comprehensiveness. Comprehensiveness, in my understanding, involves promotive, preventive, curative, and rehabilitative efforts. More recently, palliative work could also be added. But you know, the promotive and preventive – especially the promotive – address the social determinants of health, the root causes of health issues.

Regrettably, in health practice and child health, these crucial aspects are often neglected. A clear example of this was seen in the Selective Primary Health Care approach during the child survival revolution in the 1980s, known as GOBI-FFF. This approach selected certain technologies for child survival, such as oral rehydration, but neglected to address other crucial factors like water supply for diarrhea patients through intersectoral action. Subsequent packages of health care for children also fell short in adequately addressing social determinants. As you have pointed out, global sanitation, water supply, and food security remain global disasters. Failure to address these fundamental issues may hinder us from achieving outcomes which are perfectly possible.

AC: Do you hold an optimistic or pessimistic view of the current situation? Let me play devil’s advocate for a moment and ask if there might be a middle way to achieve the goals you desire. In other words, do you believe that a form of social democracy is feasible, one that combines the creative aspects of capitalism with regulations on financial globalization and trade rules to promote equity?

DS: Do I think that things are all bad, that we’ve made no progress and is there not a middle road? Looking at aggregated data, it is evident that there has been improvement, and we cannot deny that fact. However, we must acknowledge that new data, even from the US, shows some setbacks, particularly in critical areas like maternal mortality. While certain countries, including Zimbabwe, have experienced reversals since gaining independence, overall, there is an improvement trend.

AC: I don’t think we agree on this. To my knowledge, there are very few countries where inequality has actually decreased, and the disparity between the Global North and the Global South remains unchanged.

DS: No, no, I think we do agree. The data indicates that, on the whole, there has been a slight reduction in inequality between countries, primarily due to the growth of China and Brazil, among others. However, within individual countries, there has been a significant increase in inequality across the board. Specifically, the ratio of under-five mortality between the Global North and the Global South has worsened for the Global South over the last few decades.

For instance, in Sub-Saharan Africa, under-five mortality is now 11 times higher than in the Global North, which is a worse ratio than it was approximately 20 years ago. In essence, the rate of improvement in the Global North has outpaced the rate of improvement in Sub-Saharan Africa.

This is completely unacceptable. It’s completely unacceptable that there are children dying, especially in Africa and South Asia. Because, we have to remember, most of the deaths are concentrated in countries like Nigeria. I’ve seen data for the north of Nigeria which shows that 10% of children are immunized. Only 5% of children get access to oral rehydration therapy. 

AC: I wanted you to address medical students and young doctors who resemble a modern-day David Sanders, 50 to 60 years later. While we’ve discussed survival differences in Africa, we must also acknowledge that the West faces epidemics resulting from capitalist forces in alcohol, Big Food, Big Pharma, and Big Finance. These forces contribute to pandemics of diabetes, obesity, hypertension, stress, and loneliness. What lessons can young medics and health workers learn from all countries to drive appropriate changes for health? What advice would you offer them?

DS: In the first book I wrote, The struggle for health, I suggested a number of areas in which the concerned health practitioner could involve themselves. If one happens to be a researcher, there are areas of research that desperately need to be done. In my view, there is not enough research on the causes of the social determinants of health. For example, you were talking about loneliness the other day. There’s a lot of research that needs to be done on that. 

There also needs to be research done on Comprehensive Primary Health Care, including the good examples. When I speak to people, nobody seems to be able to think of any good examples. Well, we recently published a book which had some examples of Comprehensive Primary Health Care, like Sri Lanka, Costa Rica, the British National Health Service (NHS). They are imperfect, but still free at the point of delivery. 

On the side of prevention and promotion, there’s still a lot to be done. If the concerned health activist is a teacher, as I am, they can try and convey some of these ideas to people with whom they work. And of course, there’s advocacy, where it’s very important to disseminate information about and use all sorts of different tools against exploitation within health. This includes the commercial drivers of health problems and issues related to conflict of interest. For example, concerning the WHO International Code of Marketing Breastmilk Substitutes, and how global health governance is being distorted by the intervention of capital.

But I’ve gone on for too long. What should young health activists do? Ultimately, they have to become involved in social movements because although it’s great that people do research, teach, provide evidence for use by the oppressed and activist groups, unless we build a social movement—a big one, which is not just confined to health services, but also interlinks with climate change movements, with movements around gender, with movements around water, sanitation, and so on and so forth, we are not going to actually reverse the disaster that we are already in.

The interview was edited for length and adapted for reading. The whole conversation can be accessed in full on the podcast website.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.