The Bandoeng Conference of 1937: A Milestone in Health and Development

INCREASINGLY REGARDED as a milestone event, the Bandoeng (also Bandung) Conference on Rural Hygiene, held in August 1937 in what is now the third-largest city in Indonesia, capped a surge of interwar interest in “rural hygiene” and in several ways foreshadowed the World Health Organization’s famous Alma Ata Conference and Declaration of September 1978.1,2 By the 1930s and largely under the leadership of the League of Nations Health Organization (LNHO), rural hygiene had become a major focus in international health circles.3–5 It was a subject that drew attention to the overwhelming health needs of poor rural populations in Europe and in other parts of the world. These populations bore an enormous burden of disease and mortality, had limited access to modern medical providers or the benefits of scientific public health practice, and struggled with the devastating consequences of the worldwide economic depression—not least, massive nutritional deficiencies. Central and Eastern European health leaders such as Andrija Stampar of Yugoslavia and Ludwik Rajchman of Poland (who in the 1920s and 1930s also was LNHO Director) had begun to call attention to the problems of rural populations even before the Depression hit. In 1930, the LNHO called for the first conference on rural hygiene, which took place in Geneva, Switzerland, in late June and early July 1931.6 Attended by representatives of 24 European countries, it was also “observed” by representatives of 8 non-European countries (including China, India, and Japan). The conference approached the problems of rural hygiene from an intersectoral and interagency perspective and focused not only on the need to improve access to modern medicine and public health but also on the fundamental challenges of educational uplift, economic development, and social advancement. The conference devoted discussion to three basic issues: how to ensure effective medical care in rural communities, how best to organize public health services (including health education) in rural districts, and what were the most effective methods for raising the overall environmental, social, and economic status of rural areas. Specific recommendations included the use of nurses and midwives to expand health services delivery in culturally sensitive ways, experimentation with educational methods to convey health information more effectively, and the provision of cheap credit to raise housing standards. In 1932, the League of Nations delegate from India, with the support of the Chinese delegate, proposed a Conference on Rural Hygiene in Eastern Countries. Given the complex bureaucracy of the League and its constituent bodies, it took several years before the LNHO was formally able to act on this proposal. But in May 1936 the LNHO officially accepted an invitation from the Dutch government to host a conference in the Netherlands Indies (Indonesia) in 1937, and planning began in earnest. This rural hygiene conference was to be different in several ways from the European conference in Geneva. For one thing, many of the countries represented were not sovereign nations but rather colonial states in various stages of independent national development.7 Moreover, the depth of poverty was far greater and the level of education was considerably lower in much of the vastly larger Asian rural populations. Rajchman carefully weighed these factors in hand-picking his conference preparatory committee. He chose men who were knowledgeable in complementary ways and who maintained “a thoroughly sympathetic attitude towards the native population.”6 Their regional sensitivities supplemented what LNHO officials carried over from Geneva as the agenda for the Bandoeng Conference was being planned. The final report excerpted here captures the complex and composite nature of the Bandoeng proceedings. There was much that was familiar, such as the repeated recommendations of intersectoral and interagency collaboration, the emphasis on health education and broader educational reform, and urgent entreaties for the full utilization of nonmedical health personnel. But there was also much that was new, such as the open references to “rural reconstruction” and “land reform”; emphasis on honoring indigenous languages, cultures, and traditions and the populace’s “free will” in adopting plans for “betterment”; attentiveness to the primacy of nutrition; the recognition that some technological innovations may actually encourage the spread of diseases such as malaria; insistence on government responsibility for providing direct treatment for the sick; and a clear understanding of public health work as the “entering wedge” for economic development and self-governance. These elements of the Bandoeng report not only reflected the progressive attitudes of the LNHO leadership but also, probably, the values and priorities of nationalist independence movements such as that led by Gandhi in India.8 In the years following Bandoeng, especially those immediately after World War II, international health strayed from the insights and principles articulated in 1937 and turned to technology-based approaches and vertical programs. But by the 1970s, the World Health Organization’s malaria eradication campaign had failed, smallpox eradication was drawing to a close, and the provision of “primary care” services was attracting new attention in international health policy discussions. A politically mobilized Third World, the rise of India and China as major powers, and the politics of the cold war also focused attention on concerns that had not been central since the 1930s.9 These issues came into focus at Alma Ata, whose discussions were conducted in a new vocabulary but whose message clearly resonated with the rural hygiene movement from four decades before.