Biography
Mahler’s parents married in Schleswig-Holstein, Germany, and moved to Tandslet in Denmark, where Mahler was born as the youngest of seven children, of whom two died early. During his childhood his éducation sentimentale was shaped from two poles: the protestant rigour of his father, a Danish Baptist preacher whom Mahler called ‘one of the harshest prophets of doom in this century in Denmark’, and the charitable and ‘tolerant’ attitude of his mother, who grew up in a German family of physicians (Bjerager 1994: 46). Mahler was a religious child, who lived with a sense of guilt and developed the need to dedicate his life to a useful mission. His asceticism and Protestant work ethics were to fuel his entire career, with private life necessarily coming second place. At the age of fifteen Mahler began preaching but gave this up, partially in protest against his father. He chose instead to become a physician and obtained his medical degree from the University of Copenhagen in 1948.
After specialized training in tuberculosis, Mahler entered international public health work at the age of 27. From 1950 to 1951 he led an anti-tuberculosis campaign for the Red Cross in Ecuador and in 1951 he joined the World Health Organization (WHO). He worked as a senior officer attached to the WHO’s national tuberculosis programme in India until 1960, in charge of supervising the BCG (Bacillus Calmette-Guérin) vaccination campaign by the WHO and the United Nations Children’s Fund (UNICEF), which ‘then was the largest vaccine effort in world history’ (Brimnes 2010: 196). Mahler heralded the campaign in India as a success since vaccination coverage increased and public awareness of tuberculosis was raised as well. Although he gave particular importance to the claim that the campaign ‘convinced medical men that tuberculosis was primarily a public health – and not a clinical problem’ (Brimnes 2016: 120), he was far from satisfied with most medical doctors’ public health commitment and the experience fuelled his conviction that public health resources in developing countries were inadequately biased toward hospital-based medical care. From 1962 to 1969 he was Chief of the Tuberculosis Unit at WHO headquarters in Geneva and Secretary to the Expert Advisory Panel on Tuberculosis. In 1969 Mahler became the Director of the WHO’s Systems Analysis Project. At the time systems analysis was an emerging methodology for policy planning and management. It was based on computational methods and first developed at the Massachusetts Institute of Technology. The modernist emphasis on rational and scientific policy planning remained a central tenet of Mahler’s work at the WHO, an aspect which is often overlooked due to his anti-hospital care outlook on public health (Litsios 2002: 717). Mahler kept his Director position when Director-General Marcolino Gomes Candau (1953-1973) made him Assistant Director-General in 1970, responsible for the Division of Strengthening Health Services and the Division of Family Health. This was an unusual appointment, because WHO Assistant Directors-General had heretofore been recruited from the five veto power-holding countries of the United Nations (UN) Security Council. In May 1973 Mahler was elected the third WHO Director-General, a succession carefully prepared by Candau.
Upon assuming office as Director-General, Mahler announced a sweeping policy and managerial reform, if not moral revolution, of the WHO. Due to his charisma, moralism and the priest-like rhetoric that he had learned from his father, WHO staff remember the 1970s as the most idealistic period in the organization’s history. As an outspoken supporter of the New International Economic Order (NIEO) Mahler became the spearhead of the so-called Primary Health Care movement, which sought to reorient international health toward basic health needs and community self-help and to place greater emphasis on auxiliary health personnel rather than medical doctors. The Primary Health Care paradigm was developed in the early 1970s in meetings and seminars organized by the WHO, the Christian Medical Commission of the World Council of Churches and UNICEF. The peak of this revolution (and in the eyes of many also its endpoint) was the International Conference on Primary Health Care held in Alma Ata (now Almaty), Kazakhstan, in September 1978. The government of the Soviet Union, which seized the opportunity to showcase its centrally planned health system, had initiated the conference, which was sponsored jointly by the WHO and UNICEF and attended by 134 country delegations and representatives of more than 60 intergovernmental and non-governmental organizations (NGOs). The conference’s central outcome was the solemn Declaration of Alma Ata, which reiterated the principles of Primary Health Care and the NIEO, as well as the ‘human right to health’ enshrined in the WHO Constitution. Mahler himself had been sceptical of this conference, because it unduly politicized the Primary Health Care agenda. In his flamboyant speeches, which were loaded with references to Shakespeare, Montesquieu, Bismarck or T.S. Eliot, he rallied for his reform slogan of ‘Health for All by the Year 2000’ instead. The goal of Health for All was to enable all people in the world to lead economically and socially productive lives by the end of the century, which in Mahler’s eyes was a ‘realistic’ long-term aspiration (Mahler 1975: 457). Health for All was meant to mobilize all-out organizational and political change in order to implement the Primary Health Care agenda. It became the organization’s official strategy into the 1990s, at least at the level of declarations and resolutions by the World Health Assembly, the annual member-state forum and supreme governing body. Internally Mahler sought above all to convince the Directors of the six Regional Offices and the WHO member states to adopt Primary Health Care policies and shift their priorities to fieldwork. For him headquarters were not a reform engine, but rather an obstacle to change, a place where abstract guidelines and manuals were written that had little impact on the ground. Following a 1976 World Health Assembly resolution, sponsored by the Group of 77, that the WHO should cut expenses not related to technical cooperation, Mahler engaged in radical cuts in staff at headquarters. He devolved administrative authorities to the Regional Offices, which he believed were the main engines of the Health for All reform.
Mahler’s radicalism won him passionate admirers, but also many detractors. Within the WHO some staff members doubted whether the Health for All reform could be operationalized. It was even mocked by high-level staff, ‘who counted the number of days remaining until the end of the century’ (Litsios 2002: 725). In fact, Primary Health Care was hardly implemented in developing countries, not only due to lack of resources and resistance by medical professional associations, but also because the WHO regions did not assume the roles that Mahler had envisaged for them. Thus, by the end of his incumbency Mahler became a major critic of the very regionalization that he had accelerated and he blamed the organization’s disintegration into six quasi-autonomous regional offices. He regretted that many considered his decentralization policy a ‘blank cheque for pocket money’ (WHO 1987: 5), rather than a moral obligation to realize his Health for All by the Year 2000 agenda. Primary Health Care also provoked resistance outside the WHO. Already in 1979 UNICEF redefined its strategy as Selective Primary Health Care and prioritized targeted interventions such as vaccination campaigns and oral rehydration treatments of diarrheal diseases over the holistic Primary Health Care approach. Hence, the ‘Children’s Revolution’ led by UNICEF’s Executive Director since 1980, James P. Grant, was barely compatible with the social revolution Mahler was striving for. It fuelled inter-organizational rivalries between old organizational allies as well as personal rivalries between Grant and Mahler. UNICEF increasingly relied on its own medical staff rather than using the WHO’s technical guidance. So did the World Bank, the main international donor for health development, which pursued a neoliberal policy of privatizing health services by the late 1980s. This meant a further blow to Mahler’s Primary Health Care agenda. In spite of these developments, Primary Health Care has remained a major reference and was reinvigorated in the 2000s, not the least through the WHO’s 2008 World Health Report, entitled Primary Health Care: Now More Than Ever.
Due to Mahler’s scepticism with regard to ‘vertical’ interventions, it is an ironic coincidence that the WHO announced the eradication of smallpox during Mahler’s incumbency in 1979. With regard to the HIV/AIDS pandemic, however, Mahler would change his mind regarding disease-specific measures. Later he would even express his regret that he had not instantly acknowledged the threat that this new disease posed to the developing world, especially on the African continent. Yet, in 1987 Mahler hired the American HIV specialist Jonathan Mann to establish a Special Programme on AIDS and made the combat of HIV a WHO priority. The charismatic Mann enjoyed Mahler’s unconditional support and became an international health celebrity. Mann made the Global Programme on AIDS (GPA), as the programme was renamed in 1988, the WHO’s largest single disease programme that worked nearly autonomously and engaged in unconventional collaborations with grassroots NGOs. However, Mahler’s successor in 1988, Hiroshi Nakajima, was less supportive of the GPA’s special status. He considerably circumscribed the programme’s and Mann’s autonomy. Frustrated with this leadership change, Mann resigned from the WHO in 1990. His departure is reported to have demoralized the GPA staff, provoking a wave of further resignations. When in the mid-1990s the Joint United Nations Programme on HIV/AIDS (UNAIDS) was founded to serve as the UN umbrella organization for HIV/AIDS, the WHO practically dismantled its HIV activities and most of the remaining GPA staff members were transferred to UNAIDS (Hanrieder 2013). A lasting achievement of Mahler’s incumbency was the adoption of the Model List of Essential Drugs, which was first issued in 1977 and later renamed Model List of Essential Medicines. The list defined public health standards to curb a trend toward the aggressive marketing of substandard and spurious medical products in developing countries. While Mahler resisted demands by developing countries to design an international marketing code of pharmaceutical products, the model list in itself was a huge provocation aimed at pharmaceutical companies and reflected his scepticism of a purely medical approach to public health. The list defines which medicines are indispensable to assure safe and effective medical care and thereby indirectly excludes other medical products as non-essential. Both the industry and important donor states, among them the United States (US), opposed this move. In reaction to the WHO’s Essential Medicines programme, the US in 1982 pushed for a freeze in the WHO’s budget and threatened to withhold contributions. However, the WHO has updated the list every two years.
Mahler left the WHO at the end of his third term in 1988. It was only during the 1988 selection process that Mahler decided not to seek a fourth term in office. Later he conceded that he had not realized the necessary level of support, thus indicating in principle he would have been prepared to run again. However, the staff also criticized him because he had neither discussed his decision with colleagues at the WHO in advance, nor taken care of his succession. In the ensuing quarrel over Mahler’s succession, the Japanese government fervently backed his eventual successor, Nakajima, who was contested by Western states, especially the US, who favoured the Brazilian candidate Carlyle Guerra de Macedo (Chorev 2012: 156). Nakajima had an extremely bad press throughout his two terms and was criticized by Western media and member states for lack of leadership, communication skills, mismanagement and patronage (Hanrieder 2013: 11-12; Lee 2009: 83-84). In 1988 Mahler was awarded the Four Freedoms Award, category Freedom from Want, for his inspiring leadership of the WHO, helping it organize a comprehensive programme to improve health conditions throughout the developing world. Mahler’s own view of his achievements at the WHO were less sanguine. In a later article about the dire state of global health cooperation he (1997: 72) emphasized his ‘own guilt complex, stemming from having been the Director-General of WHO for so many years and having accomplished so little to change that organization’.
After leaving the WHO, Mahler continued his career in international health. He moved on to London where he became Director of the International Planned Parenthood Federation (IPPF), a US-based NGO that promoted worldwide population control and family planning. Mahler regarded this post as an opportunity to fight against population growth, an issue promoted by NGOs such as the IPPF and the Rockefeller Foundation. Population control had always been a sidelined issue at the WHO, mainly because of the fierce opposition from Catholic countries and the Vatican. The WHO’s population activities had therefore been limited to a research program on human reproduction supported by voluntary donations. For Mahler, the directorship of the IPPF thus was an opportunity to tackle what he considered a root case of health underdevelopment, namely overpopulation. He took up his new job with the usual zeal, again sacrificing much of his private life. Only once a month he travelled from London to his home in Geneva. When Mahler joined the IPPF, the darkest times of the population control movement, involving massive human rights violations such as forced sterilization campaigns (not the least in India, the country where Mahler had long worked as a tuberculosis doctor) had already passed. The movement was now joining forces with the emerging women’s rights movement. Thus when Mahler addressed the 1994 International Conference on Population and Development, convened in Cairo by the UN, he put great emphasis on reproductive rights and the empowerment of women. Interestingly, this female dimension of health and development had been missing from the Primary Health Care agenda. Mahler left the IPPF in 1995.
In his public appearances following his active international career, Mahler remained faithful to his social development approach to health and served as an idol for health activists and civil society organizations such as the People’s Health Movement. In an address to the 2008 World Health Assembly at the occasion of the 30th anniversary of the Declaration of Alma Ata, Mahler reminded the delegates of the values enshrined in the WHO constitution. He reiterated his belief in a social justice approach to public health and criticized the biomedical public health paradigm that reduced humans to medical consumers. Rather than expressing disillusionment over the fate of Health for All by the Year 2000, the then 85-year-old Mahler stated confidently that ‘visionaries have been the realists in human progression’ (www.who.int/mediacentre/events/ 2008/wha61/hafdan_mahler_speech/en).
May 2017: date of death and information Brimnes added
