“IMAGINE ALL THE PEOPLE:” ANDRIJA ŠTAMPAR’S IDEOLOGY IN THE CONTEXT OF CONTEMPORARY PUBLIC HEALTH INITIATIVES

Recently, the World Health Organization launched its Universal Health Coverage initiative with the aim to improve access to quality health care on a global level, without causing financial hardship to the patients. In this paper, we will identify and analyze the ideological similarities between this influential initiative and the work of one of the founders of the WHO—Andrija Štampar (1888–1958)—whose social medicine was built of various normative, sociological and philosophical elements. Our aim is to demonstrate the crucial role of carefully erected and thought-out ideology for the success of public health programs.

Introduction "Imagine no possessions, no need for greed or hunger … imagine all the people sharing all the world ... and the world will be as one" -proceed the verses of John Lennon's greatest musical gift to the world. 1 We repeat the dream of equality all over again in our songs and in our fantasies, but the reality often faces us with a bitter truth that we still have a long way to go.According to the World Bank and the World Health Organization (WHO), at least half of the world's population cannot obtain even the essential health services.Currently, 800 million people spend at least ten percent of their household budgets on health expenses for themselves, a sick child or other family members. 2These staggering and persistent inequalities have repeatedly been tackled by the WHO, albeit with limited success.Recently, the WHO and the World Bank had set out to address those burning questions through the introduction of the Universal Health Coverage (UHC), an initiative which stresses the need for all people to receive the health services they need without suffering financial hardship. 3The UHC is described as "an investment in human capital and a foundational driver of inclusive and sustainable economic growth and development," as well as a "way to support people so they can reach their full potential and fulfil their aspirations." 4oreover, it is implied that by progressing towards the universal coverage, "resilient societies" would be created in the process. 5Finally, the UHC initiative recognizes that factors outside the health system, such as environmental, social and economic influences play crucial roles in the success of public health programs. 6is revival of interest in universal health care began with the debates about the United Nations Sustainable Development Goals.However, the basic premise of universal health care can be traced back at least to the nineteenth century and the introduction of social security by the German chancellor Otto von Bismarck.In this paper, we will make another connection between the UHC and the past, by arguing that some of its core principles are shared with one of the most prominent public health reformers of the 1 Lennon, John (1971).Imagine, track 1 on Imagine, Apple.compact disc.first half of the twentieth century -Croatian physician and advocate of social medicine Andrija Štampar (1888-1958).Although we will only analyze the similarities between Štampar's ideology and the UHC, several other past and present initiatives have also been inspired by Štampar's work.Perhaps most famous was the Health for All strategy, which was based on a set of principles established in the 1978 Declaration of Alma-Ata.An extension of these principles can be found in the WHO Health in All Policies (HiAP), "an approach to public policies across sectors that systematically takes into account the health implications of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity." 7nother recent initiative is Planetary Health, launched in 2015 by the Lancet and The Rockefeller Foundation, 8 which also includes a new journal -The Lancet Planetary Health -dedicated to the investigation not only of the "effects of environmental change on human health," but also "the political, economic, and social systems that govern those effects." 9Finally, the important synergism of different experts in the field of healthcare is stressed in another recent initiative-the so-called One Health concept, "a worldwide strategy for expanding interdisciplinary collaborations and communications." 10In the period when medicine is getting more and more fragmented, the synergism is proposed to advance healthcare for the 21st century and beyond by "accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving medical education and clinical care." 11visaged to ameliorate some of the unpleasant facts that we face today in global healthcare, these initiatives bear striking similarities -as Gorsky and Sirrs point out -to the social medicine ideologues of the mid-twentieth century, such as one of the most prominent developers of global health and health for all concepts and one of the founders of the WHO -Andrija Štampar. 12In an attempt to follow up on the discussion started by Gorsky and Sirs, we will shift our attention to the birth of core ideological principles on which Štampar's public health was based.During Štampar's life, the concept of social diseases shaped the unquestionable faith in the importance of disease prevention, transforming physicians into social workers, while the metaphor society as an organism became a global movement and a specific cultural ethos of health protection. 13ocial misery destroys healthy people:" Štampar's national phase Andrija Štampar was born in 1888 in a small Croatian village of Drenovac, as the son of a teacher.This fact deeply influenced his whole career, as he never liberated his mind from the village and constantly emphasized rural folk's education as the primary technique of health improvement.14 He studied medicine in Vienna, where he was captivated by Julius Tandler's and Ludwig Teleky's lectures on social medicine.Later, he even befriended Tandler, who in 1920 abandoned the academic life to become the City Welfare Councilor of Vienna, and a man chiefly responsible for the development of public health services in the capital of Austria.15 Already as a student, Štampar published a paper laying out the basic tenets of a modern approach to public health.16 Following Tandler, Štampar put physical strength as the second most important ideal of the modern age, after freedom, and claimed that mankind was being "suffocated by degeneration."17 Finding in a partly privatized health system in Croatia a philosophy of individualized medicine, Štampar advocated for the adoption of a sociological point of view as a prerequisite to obtaining more palpable results in public health.For young Štampar, social medicine was a wide-ranging sociologically-and philosophically-informed discipline strongly backed by the state.
After finishing studies in 1911, Štampar began his medical career as a general practitioner in Croatia.Soon, he became disillusioned with curative medicine and went to Belgrade to meet Milan Jovanović-Batut, a well-respected physician and a staunch supporter of social medicine.Batut later recalled that Štampar immediately impressed him, and that he "knew the common people, had consistent views, fluid logical thinking and correct judgement." 18When the new state on the European southeast -the Kingdom of Serbs, Croats and Slovenes -was established after the First World War, it was Batut who recommended Štampar to the government, and he was elected the Chief of the Department of Racial, Social and Public Hygiene in the Ministry of Public Health.At that time, Yugoslavia was a rural and poor country, with 11 million inhabitants and with some of the worst health statistics in Europe.Many had doubted that an experiment which brought together nations with vastly different cultures could prove to be successful.The country obviously needed a homogenizing factor and a viable plan of regeneration, and for a decade found it in Štampar's unifying public health vision.
In the context of widespread illiteracy and raging "social diseases," Štampar strongly discouraged philanthropic vision of public health.In one of his many critical remarks about privatized healthcare, Štampar argued that a health system based on sentimentality was destined to fail, since the majority lacked the capacity to care for others. 19Consistent with the dominant hereditarian thinking of the time, he called for negative eugenics as a way of achieving Yugoslavia's rejuvenation.A devastated, fragile and ethnically diverse country needed a strong project based on objective, observable facts, and Štampar for a while thought that eugenics could be a major help in building a state ready to fight in the international political arena.In 1919, he called for the introduction of obligatory premarital examinations and proposed that those with mental disability, retardation, epilepsy and active tuberculosis be prohibited from marrying.However, his recommendation soon faced severe criticisms by his peers and legal professionals.Most importantly, it revealed a lack of support in the conservative population, so he soon distanced from biological determinism and emphasized that the root of many diseases was "social, and not germinal." 20Following "Marx's great analysis," 18 Jovanović-Batut, Milan (1934), Radovi oko unapređenja sanitetske struke i narodnog zdravlja u našoj zemlji za poslednih 60 godina, in: Štampar, A. ed., Deset godina unapređivanja narodnog zdravlja, Zagreb: Zaklada tiskare Narodnih novina, 9-10.
he also anticipated the need for regulatory bodies in factories, those modern "Roman arenas," as he slammed the exploitative nature of capitalism and debilitating effects of industrialization. 21Influenced by yet another Austrian intellectual, a writer and socialist Rudolf Goldscheid, Štampar concurred that the "economy of people" was much more important than the economy of things. 22He claimed that capitalism was rigged to benefit the wealthy, and that the advancements in technology and industry were only possible due to the sacrifices made by the sick and the underprivileged.
To address these perceived inequalities, Štampar dedicated himself to the systematic development of health institutions in Yugoslavia.Under the influence of Masaryk's idea of socially progressive programs according to which "humanity is not sentimentality," but rather "work and only work," 23 Štampar proceeded with the establishment of a network of 250 medical institutions: the Central Institute of Health in Belgrade, 6 epidemiological institutes, 19 bacteriological laboratories, 23 health centers, 2 institutes for malaria, 45 malarial health centers, 50 mobile dispensaries for venereal diseases, 34 dispensaries for tuberculosis, 13 dispensaries for trachoma, 14 dispensaries for small children, 17 school clinics and 21 village health centers. 24The role of physician was also extensively changed: she was no longer a representative of the administrative authority alienated from the populace, but was profiled to become "a public teacher." 25Public health experts educated in this new spirit of preventive medicine were directed primarily to rural areas of the country which struggled with the shortage of medical personnel.There, they battled against malaria, tuberculosis, syphilis and alcoholism, i.e., diseases that decimated both rural and urban population and which were seen as dangerous obstacles to the progress of a new and fragile nation.
It was Štampar's deep conviction that to realize his all-encompassing vision of public health, the whole society had to contribute.To that end, with the financial support of the Rockefeller Foundation, Zagreb School of Public Health was opened in 1927.A year later, Štampar founded the socalled Peasant University, an institution dedicated to adult education with different programs for women and men.While courses for women included hygiene, child-care, housekeeping and cooking, male courses were focused on various aspects of rural economy and sanitation. 26In 1929, the School started to publish a magazine dedicated primarily to students of the Peasant University.Articles were written in clear language and with simple visual guides.These Štampar's ideas on education also had deep ideological background, for already in 1919, he recommended Alfred Grotjahn's three paths to national regeneration, one of which was named orthodietetics, or medical propaganda. 27spite Štampar's palpable results, the last of which was the merging of the Ministry of Human Services with the Ministry of Public Health in 1929, he was forced to leave the government in 1931.The assassination of Croatian representatives in the Belgrade parliament in 1929, the rise of nationalism, King Alexander's dictatorship and a series of clashes with upper echelons of the government made Štampar's position untenable.
"Health should be a factor in the creation of a better life:" Štampar's international phase Štampar's Yugoslav phase coincided with the new movement within global health that was being carried out by the League of Nations Health Organization (LNHO).Along with the Rockefeller Foundation, this key agent in the development of public health organized programs for the prevention of infectious diseases, established epidemiological intelligence systems, developed international standards, promoted cooperation and education, and supported public health systems all over the world. 28Since 1923, Rockefeller Foundation's representatives regularly visited Yugoslavia.Pleased with Štampar's results, the LNHO invited a number of Yugoslav specialists to study public health issues abroad.It was the beginning of a dynamic network of international cooperation throughout which the shared experience was utilized in the creation of a modern public health system. 29etween 1933 and 1936, Štampar was associated with the League of Nations and the Rockefeller Foundation as a health expert in China.Faced with this huge country and its enormous economic and political problems, he thought he had unearthed yet another sociological law: "After my threeyear work in China I am particularly impressed with one fact.The work on the improvement of public health cannot be successful where the standard of living is lower than the minimum needed for existence." 30Although a supporter of socialist thinkers, it was in China that Štampar for the first time mentioned "guilty conscience" in the context of global healthcare.More precisely, he experienced "a certain unpleasantness in soul" because he had lived in better conditions than a countless number of "nameless" Chinese workers. 31He scorned the bourgeois way of life in times when the majority had so little, as evidenced by his 1934 letter to his colleague and future wife Desanka Ristović:

I will stay with these people, because I want to finish my work. […] And what would I do in Nanjing after all? I do not belong there, my dear Desanka.
[…] Am I to watch these shallow intellectuals, betting on the shots of strong liquor and driving in luxury automobiles with their lovers, who think that by doing that they are importing the Western civilization?I want to be here among the hungry and barefooted, rather than on some fashionable beach, watching bedizen half-naked women and swimming with them in a bubbly sea. 32tampar's notion that the powerful must help the disenfranchised has a long philosophical tradition.Even in our own times, the character of justice in a global political setting is a relevant topic, as shown by the rich discussion centered on the work by Indian economist and Nobel laurate Amartya Sen, a supporter of UHC, 33 who forcefully argued that global powers should intervene to help the troubled. 34Štampar's words were not merely an aca-demic opinion, though, but a lived-through ideology.Namely, during his dangerous travels he had to leave his five children at home.The separation increasingly troubled him, as he wrote in his diary as well as in his letters to Desanka Ristović, but never managed to crush his will to bring his experience to those who he thought needed it more. 35e fertile Chinese period also taught Štampar that public health necessitated a multidisciplinary approach that would take into account the specificities of the locale: "[…] complete success by the physician is only to be expected if his activities are combined with those of the schoolteacher, the agricultural expert, the veterinary surgeon and the engineer." 36More precisely, and remarkably similar to contemporary One Health initiative, Štampar claimed that veterinary surgeons were indispensable in rural countries, since the losses due to infectious diseases among animals "are sometimes disastrous to rural economy, causing additional distress and poverty." 37ampar visited the United States three times during the inter-war period: in 1931, 1938 and 1939.During his second visit, Štampar travelled across the States as a visiting professor at the universities of Harvard, Yale, Galveston, Columbia, Vanderbilt and many others.His activities were mentioned profusely by daily newspapers and magazines. 38Štampar was also called to give the Cutter Lecture, traditionally held by the leading experts in public health, preventive medicine and epidemiology.At that time, Franklin D. Roosevelt had already finished a series of economic programs and financial reforms that Štampar perceived as the beginning of great efforts towards the state of justice and security. 39However, he was less impressed with "superiority complex" displayed by many American physicians, who showed a remarkable "lack of knowledge about foreign medical systems." 40ampar was arrested in 1941 by the Gestapo in Zagreb and sent to Graz, Austria, where he stayed in internment until the end of the war. 41After the war, he resumed his duties in Yugoslavia and abroad as the Rector of the    For example, by The Nashville Tennessean, The Times-Picayune, The Bakersfield Californian, Capital Journal, The Baltimore Sun, The Chattanooga Free Press.39   Štampar, Andrija (1939), Novi duh u Americi: socijalno-medicinska opažanja, Liječnički vjesnik 61 (1), 80-87.

Discussion
In his comparison between Belgian physician and social worker René Sand and Andrija Štampar, Patrick Zylberman argued that it was Štampar's vision of public health that ultimately dominated the League of Nations Health Organization.Zylberman also noted that Štampar's influence stretched as far as the WHO-UNICEF conference in Alma-Ata.While we agree on these points, in a more controversial assessment Zylberman labeled Štampar's social medicine as "populist," due to its preoccupation with rural health, rural housing and education for peasants. 49Essentially, Zylberman argued that Štampar focused on "folklorizing" social medicine to make it palatable for the political establishment of an Eastern European country.Contrary to Zylberman's viewpoints, we argue that Štampar's social medicine was based on mature knowledge and experience about the targeted population.His use of films and projectors during his lectures shows the ability to adapt novel techniques to the reality of Yugoslav population.Most importantly, Štampar was a pioneer of modern community action in public health matters.He did not kowtow nor patronize; instead, he tried to strengthen the rural areas of the country from the inside, mobilizing the potential of its population.In times when public health still struggled with top-down approach, Štampar recognized the importance of the local setting, interdisciplinarity and the involvement of the whole community.His cautious approach towards eugenics and his ultimate rejection of this movement show his awareness of the limitations of the top-down approach.
And it is to this issue of how to apply broader ideological ideas to a local setting that we now turn.Štampar understood that the politics, ideas and the community all have to coalesce for any measure to be successful.Some recent authors have claimed that this profound and influential legacy is marginalized in the modern period.In a comment about the state of today's public health, the 2016 winner of ASPHER's Andrija Štampar medal Richard Horton, heralded Štampar's "inestimable" contribution to what is today known as global health.However, Horton also claimed that Štampar would most likely be displeased with some recent developments in public health, especially with its retreat from "urgent engagement in the public sphere," its reduction to "mindless metrics of academic output," its "blunted" social impact and its emphasis on "technical success over political struggle." 50s UHC a much-needed breath of fresh air, is it too idealistic, or is it just another example of what Horton labelled as "academic output"?While it is too early to tell whether this initiative will produce globally relevant results, there are some reasons for concern if we follow Horton's point of view.Clearly, the UHC initiative is based on a type of thinking that informed Štampar's reforms of public health in Yugoslavia and abroad.However, as we have demonstrated here, Štampar never failed to openly link his ideas with politics, in his case with socialism.Moreover, he even named his project "our ideology," thus giving political accent to his reforms.This should not be understood in a daily political sense, but rather as an intellectual, sociological and philosophical endeavor.
On the other hand, the UHC initiative seems ill-informed in this particular aspect.It is presented in the form of meticulous quantitative analysis, but in its attempt to appear objective, it eschews the qualitative and political analysis of the state of global health.This issue has already been identified by Greer and Méndez, who demonstrated that the accent on technical aspect of the UHC "underplays a large body of evidence suggesting that UHC is potentially transformative and intensely political, and depends on the features of a country's governance." 51Other authors have also noted that there is an inherent paradox at play in the initiative: "One aspect of the difficulty is that the leading organization promoting UHC, the WHO, while passing resolutions about UHC (2005) and writing reports about PHC (2008), has intentionally sidestepped complex political issues that are implicitly necessary to address within countries to promote UHC and action on the social determinants of health.Its normative function enables it to promote universal systems, but roles in country support can create tensions if WHO wishes to engage in political processes -which are crucial to attaining UHC." 52 One can also point out to the fact that the way in which UHC is defined leaves a lot of room for interpretations.For example, in the 2017 Global Monitoring Report, the US is presented as one of the countries with highest score on the UHC index. 53This accommodation of neoliberalism within the UHC initiative and global health in general has also been noted by some authors who analyzed the implementation of health reforms in India. 54A related issue is the empirical finding that due to its trickle-down pattern, implementation of UHC can in fact lead to more rather than less inequality. 55spite these objections, it is a testament to Štampar's vision that his notions are still being utilized at the highest institutional levels.Regrettably, the same cannot be said of the country he was born in.Since the fall of communism, public health system in Croatia has undergone several changes that suggest a substantial break with Štampar's tradition.Recently, Croatian researchers demonstrated that due to Štampar's left-wing attitudes and high-profile role in the second Yugoslavia, public health is now seen as an ideological relic from communist times, relegated to the margins of Croatian medicine by clinicians who dominate the field. 56Somewhat ironically, this course of events once again proves that Štampar was right, for he had always held that healthcare was deeply linked with social structures and politics.

Conclusion
In this paper, we have identified certain similarities, as well as differences, between the WHO's UHC initiative and Andrija Štampar's public health ideology.We have argued that Štampar's successful public health strategy resulted from three most important factors: a carefully erected ideology, an engagement with community and extensive fieldwork experience.His views and notions both reflected and shaped the idea of a world of equality.John Lennon did the same in the early 1970s, writing his famous Imagine.Yet, from imagination to realization there is still a long road.To act energetically, to pressure the governments, and to introduce and develop innovative initiatives is our duty.To follow the vision of our predecessors is our advantage, privilege and precious heritage.

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Health in All Policies: Helsinki Statement.Framework for Country Action (Geneva: World Health Organization, 2014), 2.