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David Sanders, pioneer of Health for All

When David Sanders died suddenly of a heart attack on August 30, 2019, it was a great loss. But his many friends and colleagues around the world can take heart that his passing did not leave a vacuum. To the contrary, David left a legion of fellow travelers around the world who, thanks to him, are today more strongly committed, better prepared, and have a greater sense of solidarity to continue the uphill struggle for health. After his passing, the huge outpouring of appreciation for his exemplary contribution worldwide makes it clear that his contagious spirit, boundless energy, and unflinching honesty in the face of power lives on in the vast spectrum of people - from community health workers to international movement organizers - who had the good fortune to know him.

Indeed, so many fine tributes have already been circulated in praise of David Sanders that it seems there is little more to add. Therefore, I will focus on my own personal interaction with him, which began over 40 years ago.

I first met David in the late 1970s in London, where he was working for Oxfam. At that time David was in exile from his homeland in Rhodesia, where he'd been a strong proponent for that country's independence from Great Britain's colonial rule. As a pediatrician in that land, David had an early exposure to the devastating impact that entrenched inequalities of power had on the wellness of the subservient population. Thus, in the pursuit of health and social justice, he'd become an avid activist in the grassroots movement for Rhodesia's independence. Faced with threats to his life, he went into exile to the UK, where he continued his advocacy for Rhodesia's independence.

On one of my trips to London during that time, to present a paper on "Health Care and Human Dignity", David Sanders invited me to his circle at Oxfam. He'd used my books Where There Is No Doctor and Helping Heath Workers Learn in his community health promotion in Rhodesia, and in our Hesperian newsletters he'd read about Project Piaxtla, the villager-run health program in western Mexico I'd helped start. He told me of his goal, once Rhodesia was liberated, of helping the newly independent country set up a national health program based on Comprehensive Primary Health Care, in which local community health workers - chosen for their commitment to the common good - would be agents of change in the promotion of a more equitable, just, and thereby healthier society.

No sooner did Rhodesia - now Zimbabwe - in May 1990, win its independence from the UK, then David Sanders at once returned to his homeland, where he was recruited to play a key role in forming the new Ministry of Health.

In that early realm of independence, David Sanders invited me to visit Zimbabwe, both to witness the new, people-centered mobilization that was underway, and to share some of my experiences of community-based health promotion in Mexico and elsewhere.

Part of David's motive in bringing me to Zimbabwe was for me to give presentations and exchange observations with key honchos in the new health ministry, some of whom were still wedded to the conventional model of Western (i.e., colonial) medicine, with its hierarchical pecking order and its focus on sickness rather than health.

For a while David and his cohorts made a good progress with the new, more holistic, community-centered initiative, along the lines heralded in Alma Ata as "Primary Health Care". The nation's top decision makers - still imbued with the revolutionary spirit of newly won independence, made space for this more democratic, people-empowering approach to health care. But sadly, as so often seems to happen in human history, those who had been heroes in the fight for liberation, once they rose to power, gradually became oppressors themselves. As wealth again began to concentrate at the top and the state became more authoritarian, priorities shifted. The egalitarian, more empowering community-based approach to health promotion advanced by Sanders and his colleagues fell out of favor with the controlling class - especially with the conventional medical establishment. His detractors began to hit below the belt, lambasting David as a "white colonial" who was trying to impose second-class services on what he viewed deep-down as second-class people.

This was painful for David, who was deeply committed to health and fair treatment for all. In time the barriers to advancing universal primary health care in Zimbabwe became so great that David decided to move to South Africa. At that time South Africa was still under apartheid rule, with a huge gap in wealth and health between the white elite and the black majority. But it was not without hope for change. There was a strong and growing resistance led by the African National Congress (ANC) and others. Even the medical establishment itself was divided. After the mainstream Medical Association of South African (MASA) defended a doctor who had overseen the torture of Steve Biku, an outspoken leader of the Black Consciousness Movement, a portion of MASA's members split off in protest. They then formed NAMDA (National Medical and Dental Association), which took a united stand for racial equality. NAMDA also introduced a network of community-based health care in shantytowns, providing training and backup for local, relatively unschooled, but socially committed health promoters.

As part of the coordinated effort to promote international awareness and solidarity in support the South African struggle against apartheid, David Sanders and his colleague reached out to the global health community. Among other actions, David arranged for NAMDA to invite me to visit the mushrooming shantytowns outside Johannesburg and to engage in an educational exchange with its field organizers. While there, we shared experiences and methods for implementing CBHC (community-based health care) in marginalized communities, and encouraging people to analyze the social and physical determinants of health and to work together to improve their situation.

This exchange - instigated in large part by David Sanders - took place (I believe) in 1992. The growing anti-apartheid tide was then being countered by a ruthless escalation of repression, curfews, and arrests of activists. Many in the struggle grew discouraged. But David Sanders and other leaders of NAMDA were confident that the racist regime was planting seeds of its own demise. Its draconian clampdown on protest only triggered greater resistance. ... And sure enough, in an attempt by the ruling class to quell the rising storm, Prime Minister F.W. de Klerk agreed to hold South Africa's first all-race, democratic election. In May 1994, Nelson Mandela - who had been freed after 27 years in prison - became South Africa's first president of the nation's post-apartheid era.

Much of the more recent history of David Sanders's indefatigable role in promoting health-for-all and social justice - in South Africa and worldwide - is well known to his contemporary friends and colleagues. Many have given tribute to his on-the-ground research and service-oriented training of students, which he spearheaded for decades at the University of the Western Cape. I will therefore focus here only a few more of my own undertakings with David, with which some of his younger colleagues and admirers may be less than familiar.

Everyone is aware of the seminal role that David Sanders has played in the formation and ongoing pursuits of the People's Health Movement (PHM). But fewer may be familiar with his previous key role in the International People's Health Council (IPHC), which in many ways was the precursor of the PHM.

The International People's Health Council was launched in Managua, Nicaragua, in December 1991, at the closure of a small international symposium on "Health Care in Societies in Transition". The symposium and the IPHC that grew out of it were conceived and organized by several of the same pioneers in Primary Health Care who, nine years later, in 2000, would be instrumental in midwifing the first global People's Health Assembly (PHA) and the People's Health Movement that grew out of it. These key players in launching both the IPHC and the PHM included Zafrullah Chowdhury (Bangladesh), Mira Shiva (India), David Sanders (South Africa), Maria Zuniga (Nicaragua), and myself. The idea for the symposium had initially been conceived several years before, during the Sandinistas' heyday in Nicaragua, when revolutionaries, backed by a diverse workforce of brigadistas de salud (community health brigadiers), had overthrown the tyrannical Somoza government and set up a people's republic. In a few short years, the fledgling government - backed by strong community involvement - had achieved spectacular improvements in health. Inspired by this success story, our motley group of health activists decided to hold the transitions seminar in Managua. We saw Nicaragua as a shining example of a society in transition to achieving better health. Ironically, however, we delayed too long in getting our symposium off the ground. In 1990, after years of ceaseless attacks by the US-financed "Contras" and of infiltration by the CIA, the weary population voted the Sandinistas out of power and voted in a coalition government that was puppet to US imperial interests. Rapidly the people-supportive agenda of the Sandinistas was rolled back, the gap between the rich and poor grew wider, and the population's health once again began to deteriorate. Sadly, Nicaragua was not alone in this pattern. Similar reversals in democratic process and in the health and welfare of the people were then taking place in many countries, spurred by economic globalization with its structural adjustment mandates and so-called "free trade" agreements. So our transitions seminar, initially planned to learn from societies transitioning to better health, ended up discussing transitions that were endangering and worsening the health of societies. Our seminar's challenge was to explore possibilities for reversing this retrograde process. (All this is written about in David Sanders and my book, Questioning the Solution - see below.)

We felt our seminar's analysis of the current social and political determinants of health, and possible action for coping with them, were important enough they should be recorded and shared. So Maria and I and others put together a booklet of the proceedings, which we titled Health Care in Societies in Transition (published by Health Wrights in English and by CISAS in Spanish). We also thought the dialog we had begun should be continued, with more health activists participating. Hence we launched the IPHC, which grew in size and had subsequent international meetings. The most notable of these events took place in Palestine and in South Africa - the latter adroitly organized by David Sanders.

After a few years the PHM - with a much larger cast of players - took over and expanded the role of the role of the IPHC, whose mission it continued. David Sander was a wise and dynamic spearhead of both.

David Sanders wrote over 50 groundbreaking papers and several books. His first book, The Struggle for Health: Medicine and the politics of underdevelopment, published in 1985, was a bombshell. It likely did more than any other publication to awaken the international health community to the fact that a population's health is determined more by the distribution of power and resources than by health services per se.

Over the years David Sanders and I realized we shared similar perspectives on health and social justice. In the mid-1990s we started writing a book together, which we eventually titled Questioning the Solution: The politics of Primary Health Care and child survival. I visited Cape Town and he visited California to complete it. This book is lengthier than The Struggle for Health and contains a lot of examples from Latin America (most extensively Mexico, Nicaragua, and Cuba). As a case-study, the book explores in-depth the worldwide promotion of ORS (oral rehydration solution) for treatment of diarrhea. (For this reason, with tongue in cheek, David and I titled the volume Questioning the Solution. The idea for the title was David's.) Undoubtedly, the vast promotion of mass-produced packets of ORS has substantially lowered child mortality from diarrhea. Yet, as Questioning the Solution points out, other solutions - namely homemade cereal-based drinks - may have saved even more children's lives - and done so less expensively, more quickly, and more effectively, with less dependence on a distantly-produced commercial product that may not always be available. Yet the economic leverage by Big Pharma on WHO and UNICEF to promote their commercially-produced ORS packets (which rapidly became a multi-million-dollar business) stacked the deck in their favor. So it was that the less ideal but more profit-generating option has been universally promoted, sidelining less costly, more quickly available, and potentially more effective home solutions. The consequences of this grand-slam marketeering may have cost millions of children's lives - and still does.

David Sanders felt very strongly about this exploitation of children's health and the myriad other ways in which Big Pharma, Big Sugar, Big Oil, Big Ag, Big Water, Big Media, and other corporate superpowers put profit before people - and before sustainable life on the planet.

Sadly, our companion David Sanders is no longer with us in person. But his struggle for "health for all" lives on in the minds and hands of the countless friends and students and activists whose lives he so deeply touched. We all owe it to David to indefatigably keep his action, his vision, and his passion - and his wry sense of humor - alive.