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David Sanders was founding Director of School of Public Health at the University of the
Western Cape (UWC), South Africa (1993–2019), and an internationally recognized
academic. As one of the founding members of the global People’s Health Movement, and the
co-chair from 2013–2019, he was also well-known as a health activist who was not afraid to
speak truth to power.
He was a paediatric and public health specialist, who believed passionately in the Primary
Health Care approach as envisaged in the Alma Ata Declaration of 1978. He had over 40
years’ experience in health policy and programme development in Zimbabwe and South
Africa, with a particular interest in child health and nutrition, and in optimizing human
resources for health – and specifically advocating for greater recognition and investment in
the work of Community Health Workers.
He had published extensively in these fields, as well as on the political economy of health
and globalization. The first edition of The Struggle for Health: Medicine and the Politics of
Underdevelopment, published in 1985, inspired a generation of young health care workers to
see beyond curative care, to the social determinants of health.
David was remarkable for bridging the often-divided worlds of academia, socialist politics
and activism. He combined research and service development with grassroots and global
activism, for the pursuit of health justice. The second edition of this book, with inputs by
fellow travellers, is part of David’s legacy and will contribute to furthering the struggle for
Health for All.
The Struggle for Health
The Struggle for Health
Medicine and the Politics of Underdevelopment
Second Edition
DAVID SANDERS
WITH WIM DE CEUKELAIRE
AND BARBARA HUTTON
Great Clarendon Street, Oxford, OX2 6DP,
United Kingdom
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Editors
Ms Barbara Hutton (Research Consultant and Educational Writer/Specialist)
Dr Wim De Ceukelaire (Director, Belgian NGO Viva Salud)
Reviewers
Dr Richard Carver (Co-author of the first edition of The Struggle for Health; Visiting Research Fellow, Oxford Brookes
University; Co-editor, Journal of Human Rights Practice)
Emeritus Professor Sue Fawcus (Senior Research Scholar in the Department of Obstetrics and Gynaecology, University
Cape Town, and the wife of the late Emeritus Professor Sanders)
Ms Nikki Schaay (Senior Researcher, School of Public Health, University of the Western Cape)
Consultants
Professor Fran Baum (Director, Stretton Health Equity, University of Adelaide, Australia; Extraordinary Professor at the
School of Public Health, University of the Western Cape; and Member, People’s Health Movement, Advisory Council)
Dr Chiara Bodini (Researcher, Centre for International and Intercultural Health, University of Bologna; People’s Health
Movement)
Emeritus Professor David Legge (Emeritus Scholar, School of Public Health and Human Biosciences, La Trobe University,
Australia)
Contributors
Ms Jesse Breytenbach (Book cover designer, illustrator and artist)
Ms Colleen Crawford Cousins (Illustrator and artist)
Some books sit on shelves and gather dust. Few books start a movement. The Struggle for
Health was an example of the latter.
It wasn’t just a book. It became a slogan, the name of an international university on the
politics of health for young activists, and the battle cry of the People’s Health Movement.
It also became my life.
And I was not alone. You could sit in the breakfast room of a hotel with David Sanders
anywhere in the world preparing for an international health meeting and someone would
walk up to your table to introduce themselves. Invariably the person would explain how
much The Struggle for Health had meant for their personal development and choices in life.
Some of them had made a career in health ministries or in the World Health Organization
(WHO). Others were rural doctors, staff of non-governmental organisations or health
activists. All of them testified how important the book had been for them.
In his foreword to the book’s first edition, Professor David Morley wrote: “Perhaps books
such as this will awaken those, particularly in the less developed countries of the world, to
realize that improvement in the health of the vast majority of their patients in the shanty
towns and rural areas will come largely through political change rather than through pills
and injections.” And indeed, that came through. But Morley, a pioneering paediatrician in
colonial and post-colonial Africa, was a giant of another era. It was the era of ‘tropical
medicine’, a specialty that was taught in institutions that reeked of colonialism. Alternative
analyses were rare and hard to come by, in particular, those which located health and disease
in relation to the dynamics of colonialism, racism, capitalism, patriarchy and imperialism.
Even harder to find were books like The Struggle for Health, which brought together such
an analysis with a strong ethical position around injustice, and which offered accessible
pathways into activism for health and social justice. The Struggle for Health avoids a
simplistic dichotomy between health care versus political activism; rather it points toward
ways of approaching health care which also challenge the structures which reproduce
avoidable and inequitable burdens of disease and injury.
Today, almost every medical faculty has courses on ‘global health’ and even well-
established medical journals are publishing articles on the decolonisation of health and health
care. There is a vast amount of critical material available on the internet. Nonetheless there
remains an urgent need for the analysis presented in The Struggle for Health to be updated to
recognise the changing context. Many of the ideas in the first edition have found their way
into the thinking and writing of others. But there are very few books that present an
accessible, radical and comprehensive analysis of the political economy of health. The
Struggle for Health is accessible for anyone who wants to know more about the causes of the
inequities in global health and health care. It is an invitation, an inspiration, to an activist
engagement in the struggle for health.
As we are now entering the era of climate chaos and pandemics, the book needed an
update. Whereas the first edition recognised the double burden of infectious diseases and
non-communicable diseases, these burdens have multiplied. Changing geopolitics, the
fracturing of neoliberal globalisation, the urgency of climate change and the emerging threat
of a new fascism are changing the context in which the struggle for health is embedded.
The politics, the ethics and the activist orientation remain central to this second edition of
The Struggle for Health while adapting to changing circumstances.
We hope it will inspire even more people to join the struggle and the movement.
Wim De Ceukelaire
Director
Viva Salud
Preface to Edition 1 (David Sanders, 1985)
Some time ago, a British volunteer agency published a recruiting poster which carried a
picture of the renowned German medical missionary Albert Schweitzer and the legend: “You
won’t be the first long-haired idealist to go into the jungle and teach his skills.” Unwittingly,
perhaps, this expressed a sentiment that has always underlain the relationship between
developed and underdeveloped countries—the notion of the West’s civilising mission.
This book began life in the late 1970s as a manual for volunteer British health care
workers going to work in the underdeveloped world. Over the years, it has grown into
something rather broader, which I hope will be used by others as well—by health care
workers anywhere, exploring the roots of ill-health in their societies and questioning their
roles, indeed by anyone concerned with ‘development’.
Many people can see that much ill-health is the result of widespread poverty, hunger or
unsanitary conditions. And of course, common sense tells us that ‘prevention is better than
cure’—an idea that has been enthusiastically taken up by the international health
bureaucracy. But there is still a firmly entrenched belief that the highly trained health
professional is important to the well-being of those who live in the tropical climates of the
underdeveloped world, with their ‘reservoir of diseases’.
This book offers a far more radical approach than simply the need for more preventive
medicine. It argues that medicine of any sort plays a very minor role in improving the health
of peoples—that their health is inextricably linked to the context in which they live and work.
Poverty and inequality impact on the patterns of ill-health within and across countries,
whether they are rich or poor. Improvements in health can only be made by combining more
appropriate health care with the struggle against inequality and underdevelopment. This
struggle must involve health care workers, among others.
For an overall improvement in the health of populations we need more than a heavily
doctor- and cure-oriented system of health care which only reaches a small and usually
privileged minority. The failure to radically improve nutrition, water supplies, sanitation,
living conditions and education, combined with the unequal distribution of resources and
political power within and across nations, leave many millions of people suffering and dying
from easily preventable conditions.
This book is no conventional health manual—though it has a similar starting point. It is
dedicated to the proposition that problems of health, development and underdevelopment are
intimately linked. It is for that reason that it might sometimes read like a lesson in history or
politics, rather than a book on health care. There is no reason to apologise for this. For too
long health has been widely looked upon as an issue apart from the real problems of society.
The time has come to redress the balance.
The first edition of The Struggle for Health was published in 1985 and has been widely read
and endorsed by those who seek a broader and more political understanding of ill-health that
went beyond the medical and commercial model. This revolutionary book charted new ways
of understanding and tackling the causes of ill-health, and suggested strategies to enable
Health for All. The book appealed to diverse audiences, including health care workers in both
developed and underdeveloped countries, health care workers in training, academics in health
science, sociology and health economics faculties, as well as activists for social change and
community-based workers. Many said the book was for them a ‘game changer’, ‘eye
opener’, ‘career changer’, to mention but a few of the comments received.
Since the book was written, the world has seen many changes in health and disease
burdens, and their social, economic and political determinants. Developments and challenges
related to health include, but are not limited to the HIV/AIDS epidemic; the COVID-19
pandemic; the increasing burden of non-communicable diseases; the dual burden of
malnutrition (undernutrition and overnutrition); and the increasing burden of mental health
disorders; whilst the plight of children which prompted the first edition has continued in
many parts of the world.
In relation to social determinants, poverty remains a major driver of poor health, with the
income gap between people who are rich and those who are poor increasing and lack of
access to housing, land, water and sanitation persisting for many, despite some progress.
Serious and urgent problems which have been more widely recognised in the twenty-first
century include the climate change crisis and its influence on health outcomes, armed
conflicts within and between countries that drive migration, and gender-based violence.
In the broader political and global context, we have seen globalisation with the
consolidation of multinational corporations and the predominance of neoliberal politics, the
fading of the welfare state and socially driven policies, and the emergence of new global
power alliances. Developments in Information and Communication Technology (fourth and
fifth industrial revolutions) have changed the nature of local, personal and global
communications, with mixed implications, often reinforcing existing inequities.
To counter the adverse effects of the above developments, new forms of social movements
have emerged to supplement that of organised labour, and include campaigns around social
justice issues, homelessness, the right to health, equality in education, elimination of gender-
based violence and combating climate change and its impacts.
In view of the major impacts on health from the 1980s due to the above factors, David
Sanders was in the process of updating The Struggle for Health to incorporate these issues.
He was assisted by Barbara Hutton and Wim De Ceukelaire. He was 75% through this task
when his sudden death sadly prevented him from completing the process. This project was
too important to be allowed to lapse, so a group of fellow travellers in health and politics
from the University of the Western Cape, the People’s Health Movement and others have
collectively helped to finish the book. This was done out of respect for David’s enduring
legacy, but also because we all know how important the messages and analyses in the book
are—continuing the urgent work of the struggle for health and equity.
When I first met David, I was a medical student considering giving up my studies due to
disillusionment with the narrow focus of a London teaching hospital and having been
exposed to the importance of the social determinants of health in a rural village in North
India. David encouraged me to ‘not give up’, suggesting that as a doctor there would be the
choice to be a kind, compassionate clinical doctor making individuals’ lives better, or to go
into public health and tackle the social determinants of ill-health, or to become a
revolutionary and fight to change the political system that perpetuates inequality. For David it
was not ‘either/or’; remarkably he did all three in his life’s work. All three archetypes can
become activists for social justice in health; and all three archetypes require awareness of
both the individual’s needs and the broader context.
The second edition of The Struggle for Health, therefore, has not departed from the core
message of the first edition: Health for All cannot be achieved without a change in the global
economic order, community involvement and mobilisation, social justice and a
Comprehensive Primary Health Care Approach—as enshrined in the 1978 Alma-Ata
Declaration, but watered down considerably in the 2018 Astana Declaration. This second
edition utilises the same approach as the first, with a narrative that starts with diseases, then
describes historical trends and the limitation of the medical (and commercial) model of care,
focuses on the social determinants of health, and examines the economic and political
determinants which influence both health and health care systems. It asks the question
‘WHY’ at each juncture and has used a similar analysis as in the original book to understand
and interpret all the changes since 1985. Most importantly, this second edition presents a
strengthened call to action, building upon the original work and advocating for systemic
changes to ensure justice and equity in Health for All.
Chapter 1 gives an overall impression of the conditions and diseases that most commonly
affect people globally, especially those who live in poverty within and across countries.
Chapter 2 provides a deeper description of global disease patterns. It compares the
disease pattern of European countries before they were industrialised, with diseases in
underdeveloped countries today; and finds that many diseases we now regard as ‘diseases of
poverty or underdevelopment’ were once prevalent in the northern hemisphere. However,
instead of poorer countries following the same epidemiological transition as industrialised
countries, another type of transition has evolved in which countries are struggling with more
than one dominant disease pattern at the same time. Importantly, this is increasingly polarised
across income groups, both across and within rich and poor countries.
Chapter 3 asks why this is so. How were the countries of the West able to eradicate those
illnesses which were still prevalent in the early nineteenth century? Why are their former
colonies—the underdeveloped countries—not able to? Why indeed are they still
underdeveloped? Is there a connection between development in some countries and
underdevelopment in others? In any given country, are health standards roughly equal for the
whole population? Finally, this chapter discusses the question of population—so often seen
as the crucial factor for explaining underdevelopment and poverty. Again, it compares the
population structure of industrialised countries in the eighteenth and nineteenth centuries
with that of underdeveloped countries today and asks: Is there a lesson to learn?
Chapter 4 looks at the history of medical services in those societies dominated by
imperialism, which are the foundations of the present-day health care services in both
developed and underdeveloped countries. It asks, what about the medical contribution? What
about disease prevention, treatment and cure? Does the medical contribution significantly
counteract the imbalance in the spread of health-promoting resources?
Chapter 5 examines what has happened within the context of neoliberal globalisation in
the struggle for accessible and affordable health care for all. It explores some of the forces
that have led to and shaped the privatisation and commercialisation of health care.
Chapter 6 isolates the various influences that have shaped the dominant medical model.
It explores the role of doctors, of big business interests and of the State, looking at the areas
where the three interact. Is it possible to make the necessary changes in this model, in either
developed or underdeveloped countries, while the commercial determinants of health are still
at work?
Chapter 7 asks, what are some alternatives to the medical model? To answer this
challenge, the examples of China and Cuba in the twentieth century are given, where
victorious popular struggles resulted in a change of economic and political systems, enabling
underdevelopment to be successfully tackled and great improvements in peoples’ health to be
made. Significant changes and sometimes reversals in the last few decades for these two
countries are discussed. State-led community health worker programmes in Ethiopia, Iran
and India are examined as more recent examples of alternative approaches to health care and
promotion. Finally, the chapter describes the global movement for the right to health, the
People’s Health Movement, which grew out of these alternative models.
Throughout his life David directed his energies to working with communities in struggle,
whilst also challenging power and inequality in global forums, and performing rigorous
academic research to provide evidence for the strategies he (and others) advocated for. These
features are all central aims of the People’s Health Movement which he helped to found and
which he was a part of for many years. David never gave up on the struggle for health,
against all the odds, and this second edition is part of his legacy.
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valóságos élő hús tapad. Nem választhatjuk el tőle. A Gloriosus
húsát alakjai adják meg. Figyeljük meg tehát a Gloriosus s ez által a
plautusi komédia másik fő-elemét: a jellemzést. Az atellai játékokban
a szereplő személyek Maccust, az egyedüli eredeti mimust kivéve,
mind a görög szatirjátékok alakjainak utánzatai voltak; a régi
együgyű Bakko, Dorsennus, Pappus s a szatirok családjából
származott többi alak szerepelt bennök új maszk alatt. A comoedia
palliata tehát, mely amint alakját egészen a görög vígjátéktól vette
kölcsön, anyagát is a görög vígjátéktól s ezen kívül csak az atellai
játékokból merítette, szükségképpen csak görög típusokat
tartalmazhatott. A Plautus alakjai tehát nemcsak névleg görögök,
mint a comoedia palliata alakjai egyáltalában, de származásukat
illetőleg is görög karakterek. Ezekből állott ki a Gloriosus egész
személyzete is.
Magában a hazug, dicsekvő Pyrgopolinicesben, aki elhagyva
kétezer éves sírját, egész parazita és rabszolga kiséretével jelent
meg Nemzeti Színházunk deszkáin, a szájhős katonán is
fedezhetünk föl egyes vonásokat, melyek közösek az irodalom-
történet által a görög Dorsennus-típusról följegyzett adatokkal. Pedig
a hetvenkedő maga a komédia leghatározottabban jellemzett alakja.
Hazugsága, nagy szája, gyávasága, aljas szenvedélyei, képzelgő
önhittsége élesen karakterizálják. Ha nem is törvényes fia
Dorsennusnak, kétségen kívül ősapja Capitanonak, a Commedia
dell’arte állandó hazug hetvenkedőjének, akit Arlecchino minden
darab végén megütlegel.
De csaknem annyi rokonsága van Pantaloneval is; legalább
Philocomasium őrizése, gyors szerelmi lobbanása, nevetségessé
tétele (azáltal, hogy mindenki ellene esküszik, mint Pantalone ellen
szokás), – mind a vén velencei kereskedőre emlékeztetnek. De
amint Plautus magvetője volt az egész modern komédiának,
Pyrgopolinices is ősévé vált egy egész irodalmi családnak. Ez
mutatja életerejét. Királyi ivadékok: sir John Falstaff, sir Andrew
Aguecheek stb. tőle származtak.
Pyrgopolinices mellett a parazita méltó különösebb figyelemre.
Tudvalevőleg az élősdi állandó alakja volt a görög s a római
színpadnak, úgy, hogy többféle fajúakat lehetett köztük
megkülönböztetni. A Gloriosus Artrogusa a gelotopoioszok közül
való; mindenkit gúnyoló, s minden gúnyt tűrő mulatságos fickó, aki
csak azért adta magát a parazita aljas szolgálataira, hogy
gyomrának élhessen. Igen jó alakok még a rabszolgák is: az eszes,
agyafúrt Palaestrio, őse a Zanniknak, Scapinonak, a Sganarelleknek
s a clownok és graciosok egész gárdájának. A másik szolga,
Sceledrus, a comedia dell’arte milanoi Beltramjának és
Narcissimojának élőképe; együgyű bohóc, a kómikus alakok
leggroteszkebb fajából. Ez a négy főszereplő mozgatja a darab elég
gyorsan járó gépezetét, a szerelmes párok, a kedélyes öreg, a víg
leányok stb. elmosódnak.
III.
SHAKSPERE.
A Velencei Kalmár.
(Shakspere S felvonásos komédiája, fordította Ács Zsigmond. Új
betanulással először adták a Nemzeti Színházban 1889 szeptember 6.-
án.)
SHAKSPERE
A Makrancos Hölgy.
(Vígjáték 5 felvonásban, fordította Lévay József. Új betanulással adták a
Nemzeti Színházban 1886 október 10.-én.)
LOPE DE VEGA.
Király és pór.
(Színmű 4 felvonásban, Förster átdolgozásából fordította Sziklai János.
Első előadása a Nemzeti Színházban 1889 március 8.-án.)
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