World Health Organization (Global Institutions)

The World Health Organization (WHO) The World Health Organization, as the United Nations specialized agency for health...

Author: Kelley Lee

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The World Health Organization (WHO)

The World Health Organization, as the United Nations specialized agency for health, has been at the center of international health cooperation for over 60 years. With origins dating from the nineteenth century, the WHO’s mandate is the attainment by all people of the highest possible level of health. The huge challenge of fulﬁlling this objective has not only required high-level technical skills, but has led the organization to engage with a broad range of political and economic interests. The WHO has enjoyed many high-proﬁle successes such as the global eradication of smallpox and control of SARS, and ongoing campaigns against polio and other diseases. On other issues, such as essential drugs, tobacco control, and diet and nutrition, eﬀorts to tackle the broader determinants of health have brought the organization into contact with issues such as globalization, poverty, social justice, and human rights. Drawing on the insights of the author, who has worked with and analyzed WHO activities over the past 15 years, this book oﬀers the most comprehensive analysis of the WHO available. Kelley Lee analyses the WHO’s role in international cooperation, examining its changing structures, key programs, and individuals. Of particular focus are the challenges the WHO has faced in recent years, given the emergence of other global health initiatives, and how the WHO has sought to remain eﬀective as the “world’s health conscience” within an increasingly complex global context. The World Health Organization (WHO) will appeal to students, scholars, and all those interested in public health, development studies, and international relations. Kelley Lee is Reader in Global Health at the London School of Hygiene and Tropical Medicine. Her research focuses on communicable and noncommunicable diseases, and the implications for global governance. Her books include Globalization and Health: An Introduction (2003) and Global Change and Health (2005).

Routledge Global Institutions Edited by Thomas G. Weiss The CUNY Graduate Center, New York, USA and Rorden Wilkinson University of Manchester, UK

About the Series The Global Institutions Series is designed to provide readers with comprehensive, accessible, and informative guides to the history, structure, and activities of key international organizations. Every volume stands on its own as a thorough and insightful treatment of a particular topic, but the series as a whole contributes to a coherent and complementary portrait of the phenomenon of global institutions at the dawn of the millennium. Books are written by recognized experts, conform to a similar structure, and cover a range of themes and debates common to the series. These areas of shared concern include the general purpose and rationale for organizations, developments over time, membership, structure, decision-making procedures, and key functions. Moreover, current debates are placed in historical perspective alongside informed analysis and critique. Each book also contains an annotated bibliography and guide to electronic information as well as any annexes appropriate to the subject matter at hand. The volumes currently published or under contract include:

The United Nations and Human Rights (2005) A guide for a new era by Julie Mertus (American University)

The UN General Assembly (2005) by M.J. Peterson (University of Massachusetts, Amherst)

The UN Secretary General and Secretariat (2005) by Leon Gordenker (Princeton University)

Internal Displacement (2006) Conceptualization and its consequences by Thomas G. Weiss (The CUNY Graduate Center) and David A. Korn

United Nations Global Conferences (2005) by Michael G. Schechter (Michigan State University)

Global Environmental Institutions (2006) by Elizabeth R. DeSombre (Wellesley College)

The UN Security Council (2006) Practice and promise by Edward C. Luck (Columbia University) The World Intellectual Property Organization (2006) Resurgence and the development agenda by Chris May (University of Lancaster) The North Atlantic Treaty Organization (2007) The enduring alliance by Julian Lindley-French (European Union Centre for Security Studies) The International Monetary Fund (2007) Politics of conditional lending by James Raymond Vreeland (Yale University) The Group of 7/8 (2007) by Hugo Dobson (University of Shefﬁeld) The World Economic Forum (2007) A multi-stakeholder approach to global governance by Geoffrey Allen Pigman (Bennington College) The International Committee of the Red Cross (2007) A neutral humanitarian actor by David P. Forsythe (University of Nebraska) and Barbara Ann Rieffer-Flanagan (Central Washington University) The Organization for Security and Co-operation in Europe (2007) by David J. Galbreath (University of Aberdeen)

United Nations Conference on Trade and Development (UNCTAD) (2007) by Ian Taylor (University of St. Andrews) and Karen Smith (University of Stellenbosch) A Crisis of Global Institutions? (2007) Multilateralism and international security by Edward Newman (University of Birmingham) The World Trade Organization (2007) Law, economics, and politics by Bernard M. Hoekman (World Bank) and Petros C. Mavroidis (Columbia University) The African Union (2008) Challenges of globalization, security, and governance by Samuel M. Makinda (Murdoch University) and F. Wafula Okumu (Institute for Security Studies) Commonwealth (2008) Inter- and non-state contributions to global governance by Timothy M. Shaw (Royal Roads University and University of the West Indies) The European Union (2008) by Clive Archer (Manchester Metropolitan University) The World Bank (2008) From reconstruction to development to equity by Katherine Marshall (Georgetown University)

Contemporary Human Rights Ideas (2008) by Bertrand G. Ramcharan (Geneva Graduate Institute of International and Development Studies) The United Nations High Commissioner for Refugees (UNHCR) (2008) The politics and practice of refugee protection into the twenty-ﬁrst century by Gil Loescher (University of Oxford), Alexander Betts (University of Oxford), and James Milner (University of Toronto) The International Olympic Committee and the Olympic System (2008) The governance of world sport by Jean-Loup Chappelet (IDHEAP Swiss Graduate School of Public Administration) and Brenda Kübler-Mabbott Institutions of the Asia-Paciﬁc (2009) ASEAN, APEC, and beyond by Mark Beeson (University of Birmingham) Internet Governance (2009) The new frontier of global institutions by John Mathiason (Syracuse University) The World Health Organization (2009) by Kelley Lee (London School of Hygiene and Tropical Medicine) International Judicial Institutions (2009) The architecture of international justice at home and abroad by Richard J. Goldstone (Retired Justice of the Constitutional Court of South Africa) and Adam M. Smith

Institutions of the Global South (2009) by Jacqueline Anne Braveboy-Wagner (City College of New York) Global Food and Agricultural Institutions (2009) by John Shaw Shaping the Humanitarian World (2009) by Peter Walker (Tufts University) and Daniel G. Maxwell (Tufts University) The International Organization for Standardization and the Global Economy (2009) Setting standards by Craig N. Murphy (Wellesley College) and JoAnne Yates (Massachusetts Institute of Technology) Organisation for Economic Co-operation and Development by Richard Woodward (University of Hull) Non-Governmental Organizations in Global Politics by Peter Willetts (City University, London) The International Labour Organization by Steve Hughes (University of Newcastle) and Nigel Haworth (The University of Auckland Business School) Global Institutions and the HIV/ AIDS Epidemic Responding to an international crisis by Franklyn Lisk (University of Warwick)

African Economic Institutions by Kwame Akonor (Seton Hall University)

Transnational Organized Crime by Frank Madsen (University of Cambridge)

The United Nations Development Programme (UNDP) by Elizabeth A. Mandeville (Tufts University) and Craig N. Murphy (Wellesley College)

Governing Climate Change by Peter Newell (University of East Anglia) and Harriet A. Bulkeley (Durham University)

The Regional Development Banks Lending with a regional ﬂavor by Jonathan R. Strand (University of Nevada, Las Vegas) Multilateral Cooperation Against Terrorism by Peter Romaniuk (John Jay College of Criminal Justice, CUNY) Peacebuilding From concept to commission by Robert Jenkins (University of London)

Millennium Development Goals (MDGs) For a people-centered development agenda? by Sakiko Fukada-Parr (The New School) Regional Security The capacity of international organizations by Rodrigo Tavares (United Nations University) Human Development by Maggie Black

For further information regarding the series, please contact: Craig Fowlie, Publisher, Politics & International Studies Taylor & Francis 2 Park Square, Milton Park, Abingdon Oxford OX14 4RN, UK +44 (0)207 842 2057 Tel +44 (0)207 842 2302 Fax [email protected] www.routledge.com

The World Health Organization (WHO)

Kelley Lee

First published 2009 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 270 Madison Avenue, New York, NY 10016 Routledge is an imprint of the Taylor & Francis Group, an informa business This edition published in the Taylor & Francis e-Library, 2008. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.”

© 2009 Kelley Lee All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Lee, Kelley, 1962The World Health Organization (WHO) / Kelley Lee. p.; cm. – (Global institutions series) Includes bibliographical references and index. 1. World Health Organization. 2. World Health Organization – History. I. Title. II. Series. [DNLM: 1. World Health Organization. 2. International Agencies. 3. History, 20th Century. 4. History, 21st Century. 5. International Agencies – history. 6. International Cooperation. 7. World Health. WA 530 MW6 L478w 2008] RA8.L45 2008 362.1 – dc22 2008003477 ISBN 0-203-02973-9 Master e-book ISBN

ISBN 978-0-415-37017-2 (hbk) ISBN 978-0-415-37013-4 (pbk) ISBN 978-0-203-02973-2 (ebk)

Contents

List of illustrations Foreword Acknowledgments List of abbreviations Introduction

x xi xv xx 1

1

Creation of the World Health Organization

12

2

Structure and functions

25

3

Global campaigns against disease

46

4

Tackling the broad determinants of health

71

5

From international to global health

99

Notes Select bibliography and electronic resources Index

129 146 148

Illustrations

Figures 2.1 4.1

5.1

The cluster structure of the World Health Organization 31 Former directors-generals (Brundtland, Mahler, Nakajima) and then serving Director-General (Lee) at the 25th Alma Ata Celebration in 2003 86 World Bank health lending versus WHO budget, 1984–96 112

Tables 2.1 2.2 2.3

3.1

Regional oﬃces of the World Health Organization Proportion of WHO budget from RBFs and EBFs by selected biennia Payment status of member states and associate members in respect of current-year contributions to the eﬀective working budget Selected mass campaigns against disease by WHO

32 40

42 48

Boxes I.1 1.1 2.1 4.1 4.2 4.3 4.4 5.1 5.2

René Sand and social medicine Brock Chisholm as the ﬁrst WHO Director-General Marcolino Gomes Candau Halfdan Mahler Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 1978 Hiroshi Nakajima The WHO Prequaliﬁcation Project Gro Harlem Brundtland Brundtland puts health on the world stage

8 15 28 74 76 83 93 103 107

Foreword

The current volume is the twenty-seventh in a dynamic series on “global institutions.” The series strives (and, based on the volumes published to date, succeeds) to provide readers with deﬁnitive guides to the most visible aspects of what we know as “global governance.” Remarkable as it may seem, there exist relatively few books that oﬀer in-depth treatments of prominent global bodies, processes, and associated issues, much less an entire series of concise and complementary volumes. Those that do exist are either out of date, inaccessible to the non-specialist reader, or seek to develop a specialized understanding of particular aspects of an institution or process rather than oﬀer an overall account of its functioning. Similarly, existing books have often been written in highly technical language or have been crafted “in-house” and are notoriously self-serving and narrow. The advent of electronic media has helped by making information, documents, and resolutions of international organizations more widely available, but it has also complicated matters. The growing reliance on the Internet and other electronic methods of ﬁnding information about key international organizations and processes has served, ironically, to limit the educational materials to which most readers have ready access—namely, books. Public relations documents, raw data, and loosely refereed web sites do not make for intelligent analysis. Oﬃcial publications compete with a vast amount of electronically available information, much of which is suspect because of its ideological or selfpromoting slant. Paradoxically, the growing range of purportedly independent web sites oﬀering analyses of the activities of particular organizations has emerged, but one inadvertent consequence has been to frustrate access to basic, authoritative, critical, and well-researched texts. The market for such has actually been reduced by the ready availability of varying-quality electronic materials.

xii

Foreword

For those of us who teach, research, and practice in the area, this access to information has been particularly frustrating. We were delighted when Routledge saw the value of a series that bucks this trend and provides key reference points to the most signiﬁcant global institutions. They know that serious students and professionals want serious analyses. We have assembled a ﬁrst-rate line-up of authors to address that market. Our intention, then, is to provide one-stop shopping for all readers—students (both undergraduate and postgraduate), negotiators, diplomats, practitioners from nongovernmental and intergovernmental organizations, and interested parties alike—seeking information about the most prominent institutional aspects of global governance.

The World Health Organization Intergovernmental attempts to regulate health have a long history in global governance. The health consequences of the Industrial Revolution and the social impact of increased international trade focused the minds of European and North American elites on the necessity for an international apparatus to deal with health concerns in the second half of the nineteenth century. For most of the nineteenth century, international cooperation on health took the form of ad hoc conferences on matters such as sanitation, the opium trade, and the working and living conditions of the laboring classes. Yet, these conferences were seen as insuﬃcient responses to issues of pressing concern. Inevitably, formal institutional forms followed, most notably the Pan-American Sanitary Bureau in 1902 and, some ﬁve years later, the ﬁrst international health organization: the Oﬃce International d’Hygiène Publique (OIHP). Both of these organizations pre-dated the creation of the League of Nations—the point at which those of us who teach global governance like to tell our students that something like a worldwide institutional structure for international cooperation began to emerge. Like the international public unions that were also established earlier in the nineteenth century (to regulate telecommunications and postal ﬂows),1 and a growing body of non-state actors (such as the League of Red Cross Societies—latterly the International Federation of Red Cross and Red Crescent Societies),2 they proved to not only be leaders in creating a network of national, regional, and international institutions dealing with health, but also seminal bodies driving forward the wider system of global governance. These early institutions and the issues that they sought to address in turn encouraged the creation of the League of Nations Health Organization (1920) and later the World

Foreword

xiii

Health Organization (1948) as well as provided the impetus for the move by the International Labour Organization (ILO) into health and by UNICEF (the UN Children’s Organization, created in 1946) into maternal and child health.3 The story of the emergence and development of a system of health governance is not, however, one simply of institutional innovations resulting from action arising from health concerns. From the very outset, international health governance has been deeply political, in terms both of the purposes for which its development was sought and its instruments deployed as well as of the shenanigans that have surrounded the development of its core institutions. The WHO is no exception. From the outset the WHO was caught up in great-power and Cold War politics. Like so many other sister organizations (the ILO, United Nations Educational, Scientiﬁc and Cultural Organization, UNESCO, and the International Atomic Energy Agency, IAEA, to name but three),4 the WHO saw various members leave and rejoin in accordance with the beat of world politics, and the specter of Cold War politics was never far from sight. The Soviet bloc left en masse in 1949; disagreements raged over the rightful occupant of the Chinese seat; membership of the so-called divided nations (North Korea, East Germany, and North Vietnam) proved politically inﬂammatory; and the Palestinian Liberation Organization’s (PLO) 1979 application for membership was deeply controversial. The WHO has continued to generate controversy and become enmeshed in global politics as it has strived to champion myriad health concerns throughout its 60-year history. Its work on HIV/AIDS has brought it into conﬂict with US foreign policy (and right-wing Christian lobby groups), the promotion of the Framework Convention on Tobacco Control (FCTC) has proved deeply unpopular with the tobacco industry,5 and the WHO’s issuing of a warning for people traveling to Toronto during the 2003 SARS (Severe Acute Respiratory Syndrome) epidemic brought the organization into direct conﬂict with the Canadian government.6 Understanding the WHO and its role in health governance, then, also requires an appreciation of the political climate in which it has found itself. To do justice to the WHO and its role in health governance, we needed someone with an acute knowledge not only of the institution but also of the politics of the organization. We were delighted, then, when Kelley Lee agreed to write this book for us. Kelley, currently head of the Public and Environmental Health Research Unit and coDirector of the Centre on Global Change and Health at the London School of Hygiene and Tropical Medicine, is one of the world’s leading

xiv Foreword experts on global health governance. She has written extensively on international and global health governance, the WHO, tobacco control, intellectual property and pharmaceutical drugs, health sector reform, health and security, cholera, globalization and health, avian ﬂu and inﬂuenza, and HIV/AIDS across the social and medical sciences.7 She is, in a nutshell, the perfect person to write this book. Needless to say, Kelley has produced a book that is jam-packed with information. The book exudes authority; it is detailed yet accessible; and it could only be written by someone with the keenest of analytical skills. As readers will quickly become aware, the book is an invaluable resource. It clearly deserves to be read by all interested in the politics and political economy of global health governance as well as global governance more generally. We heartily recommend it; and, as always, we welcome comments from readers. Thomas G. Weiss, The CUNY Graduate Center, New York, USA Rorden Wilkinson, University of Manchester, UK August 2008

Acknowledgments

The analysis undertaken in this book is a personal balancing act between my roles as a scholarly observer of the activities of the World Health Organization (WHO) and as a consultant contributing to speciﬁc aspects of its work program over the past 15 years. In 2006 the designation of the Centre on Global Change and Health at the London School of Hygiene & Tropical Medicine as a WHO collaborating center formalized this long-standing working relationship. Being too close to an organization when writing such a book, of course, runs the risk that one feels inhibited in making criticisms or ﬁnding fault. This is added to by my limited experience of the three organizational levels of the WHO and its labyrinthine programs. My contact with the WHO has been largely at the headquarters level, and less so with programs in the regional and country oﬃces. All of this invariably leads to a degree of subjectivity in the perspectives presented here. From this starting point, I have tried in this book to provide an understanding of the role of the WHO, and the key pressures that have shaped its creation, evolution and aspirations. Undoubtedly, the WHO has suﬀered its fair share of failures in fulﬁlling its mandate, and has been as guilty of nepotism, bureaucratic inertia and ineﬃciency as any large international organization. Yet the WHO has also been responsible for arguably the most spectacular achievement in the history of international cooperation, the eradication of smallpox, and is approaching similar success with polio. It also successfully carries out a broad range of everyday, low-key activities—collection and collation of data, setting of clinical guidelines, provision of technical expertise—all of which can be easily overlooked in today’s world of headline-driven policy making. What is perhaps disheartening for many WHO observers is the belief, or at least the hope, that international health cooperation can somehow rise above the political wranglings that can paralyze other parts of the UN system. This has not proven the case to date, and eﬀorts from

xvi

Acknowledgments

both sides of the political spectrum to “depoliticize” the organization have met with repeated disappointment. My intent, in this book, is to locate the WHO within, rather than seek to remove it from, the messy world of international relations. This world has continually changed over the past six decades, accompanied by shifting conﬁgurations of interests, institutions and ideas that the WHO has been required to adapt to. In most recent times, the transition from “international” to “global” health has perhaps been the most challenging for the WHO because of the threat of irrelevance. As other global health initiatives proliferate, the WHO faces an urgent need to deﬁne and assert a clear and eﬀective role for itself, as never before. During the past several years, I have been fortunate to work with many colleagues who have generously shared their experiences and ideas, for which I remain extremely grateful. While the views expressed in this book are solely my own, I wish to thank the following people for helping me to understand a complex and key international organization. Firstly, thanks to my current and former colleagues at the London School of Hygiene & Tropical Medicine, notably Anne Mills and Gill Walt, who provided insightful comments on a major section of this manuscript. I am grateful also to Kent Buse, Lucy Gilson, Kathleen Kay, Laura Hawken, Karen Bissell and Sue Collinson with whom I have compiled data, analyzed programs and budgets, and endlessly discussed functions and mandates over many years. Patrick Vaughan and Adetokunbo Lucas provided leadership through turbulent terrain during the 1990s during two major studies of the WHO (Oslo I and Oslo II). As a team member, I learned a great deal about the organization from them. More recently, my involvement in the WHO Commission on the Social Determinants of Health with Ronald Labonte, Ted Schrecker, Meri Koivusalo, Eeva Ollila and other members of the Globalization Knowledge Network helped me think through key challenges for strengthening global health governance. And I have discovered that international health and critical theory are eminently compatible after all, as a result of working with Colin McInnes, Owain Williams and Simon Rushton at the Centre on Health and International Relations at the University of Aberystwyth, and Alan Ingram at University College London. I am also grateful to David Fidler for his willingness to always share his work and ideas on global health governance with me. A large number of present and former WHO staﬀ have shared their insights on speciﬁc aspects of the WHO’s work including Robert Beaglehole, Douglas Bettcher, Sandy Cocksedge, Benedicke Dahl, Nick Drager, Tim Evans, Bob Fryatt, Ann Kern, Cathy Roth, Guenael Rodier,

Acknowledgments

xvii

Mike Ryan, Johannes Sommerfeld, Harley Stanton, David Woodward and Derek Yach. I am also indebted to individuals from within civil society who have shared their experiences at the front line of health development, including Mary Assunta, David McCoy, Thelma Narayan, Mike Rowson and Ellen t’Hoen. In covering such a wide range of health topics for this book, I could not have coped without the invaluable support of Andrew Harmer, who took on the diﬃcult task of collecting, reviewing and summarizing big piles of material in response to a long and rather haphazard list, and reading the entire manuscript. He made me think that the task of writing this book was actually doable after all. Finally, Melanie Batty and Ela Gohil provided much-needed administrative support with their usual eﬃciency.

Abbreviations

ACT AFRO AgDW AIDS AMRO APED ART ARVs BMJ CCS CDC CFI CMH CO CSDH CSI CSOs CVI DALYs DDT DG DNA DNDI DPT EB EBFs ECOSOC EMRO EPI EPTA

artemisinin-based combination therapies WHO regional oﬃce for Africa Third World Action Group acquired immune deﬁciency syndrome WHO regional oﬃce for the Americas WHO Action Programme on Essential Drugs anti-retroviral treatment anti-retroviral drugs British Medical Journal Country Cooperation Strategies Centers for Disease Control Country Focus Initiative WHO Commission on Macroeconomics and Health WHO country oﬃces Commission on the Social Determinants of Health Civil Society Initiative civil society organizations Child Vaccine Initiative disability-adjusted life years Dichloro-Diphenyl-Trichloroethane Director-General deoxyribonucleic acid Drugs for Neglected Diseases Initiative diphtheria, pertussis and tetanus vaccine the Executive Board of WHO extrabudgetary funds UN Economic and Social Committee WHO regional oﬃce for the Eastern Mediterranean WHO Expanded Programme on Immunization Expanded Programme for Technical Assistance

Abbreviations EURO FCA FCTC GATS GAVI GDP GFATM GHSS GPA GPEI GPPPs HALE HIV IAAG ICRC IEC IHR ILO IMF INB ITU LMICs LNHO MCH MDGs MSF MTSP NGOs NIEO OAU OECD OIHP OPV ORT PAHO PASB PEPFAR PHA PHC PLO

WHO regional oﬃce for Europe Framework Convention Alliance Framework Convention on Tobacco Control General Agreement on Trade and Services Global Alliance for Vaccines and Immunization gross domestic product Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria Global Health Sector Strategy for HIV/AIDS Global Programme on AIDS Global Polio Eradication Initiative global public-private partnerships healthy life expectancy human immunodeﬁciency virus Interagency Advisory Group on AIDS International Committee of the Red Cross information, education and communication International Health Regulations International Labour Organization International Monetary Fund Intergovernmental Negotiating Body International Telecommunication Union low- and middle-income countries League of Nations Health Organization maternal and child health Millennium Development Goals Médecins sans Frontières medium-term strategic plan nongovernmental organizations New International Economic Order Organization of African Unity Organisation for Economic Co-operation and Development Oﬃce International d’Hygiène Publique oral polio vaccine oral rehydration therapy Pan American Health Organization Pan American Sanitary Bureau President’s Emergency Plan for AIDS Relief People’s Health Assembly primary health care Palestine Liberation Organization

xix

xx

Abbreviations

POPs PRC PVD R&D RBFs RBM SAGE SAPs SARS SEARO SEP STD TAB TFCS TFI TRIPS UN UNAIDS UNCTAD UNDP UNESCO UNFPA UNHCR UNICEF UNODC UNRRA WCDE WFP WHA WHO WIPO WPRO WR WTO

persistent organic pollutants People’s Republic of China WHO Programme for Vaccine Development research and development regular budget funds Roll Back Malaria Scientiﬁc Advisory Group of Experts structural adjustment programs Severe Acute Respiratory Syndrome WHO regional oﬃce for Southeast Asia Smallpox Eradication Programme sexually transmitted disease Technical Advisory Board Task Force for Child Survival Tobacco Free Initiative Trade Related Intellectual Property Rights United Nations Joint United Nations Programme on HIV/AIDS United Nations Conference on Trade and Development United Nations Development Programme United Nations Educational, Scientiﬁc and Cultural Organization United Nations Population Fund the Oﬃce of the UN High Commissioner for Refugees UN Children’s Emergency Fund United Nations Oﬃce on Drugs and Crime UN Relief and Rehabilitation Administration World Commission on Environment and Development World Food Programme World Health Assembly World Health Organization World Intellectual Property Organization WHO regional oﬃce for Western Paciﬁc WHO Representative World Trade Organization

Introduction History of international health cooperation

The World Health Organization (WHO) was formally established in 1948 as the United Nations (UN) specialized agency for health. Its creation, however, was preceded by a long history of international cooperation dating back many centuries. Historical accounts of the inﬂuenza pandemic of 412 BC, the Plague of Athens in 430 BC (believed to have been typhus), the infamous Black Death (bubonic plague) of the fourteenth century, and so-called Columbian exchange of infectious diseases between the eastern and western hemispheres from 1492,1 are all examples of the enduring challenge of preventing and controlling the spread of diseases across continents.2 For the history of modern public health, the growth of international health cooperation from the ﬁrst half of the nineteenth century is notable. The social and economic changes brought by the Industrial Revolution had increased the vulnerability of large populations to epidemic diseases. Eﬀorts were undertaken by individual governments to strengthen collective measures to prevent and control their spread. In England, Sir Edwin Chadwick, then Secretary to the Poor Law Commission, issued the groundbreaking Report on the Sanitary Condition of the Labouring Population of Great Britain in 1839. The report revealed that, for every person who died of old age or violence, eight died of speciﬁc diseases. During the 1820s and 1830s, under-ﬁve infant mortality rates reached almost one-third. Chadwick, who went on to become one of the leading social reformers of his day, used these ﬁndings to generate widespread attention and policy measures to improve sanitary conditions, and thus public health, throughout the country. This was spurred, in part, by growing scientiﬁc knowledge of the causes of ill-health, such as germ theory (pathogenic theory of medicine). Alongside domestically focused eﬀorts, governments recognized the need for greater cooperative action across countries. The acceleration

2

History of international health cooperation

of European imperialism during the nineteenth century, later joined by the United States and Japan, prompted large-scale movements of trade, capital and people. The major social changes which ensued, in the form of rapid urbanization, increased population mobility, and wide socioeconomic inequalities, created conditions ripe for the increased spread of epidemic diseases such as inﬂuenza, cholera, typhoid, typhus and tuberculosis. Epidemics during the eighteenth century had been “more scattered and isolated,”3 and there was even a marked decline in such illnesses as diphtheria and inﬂuenza. Even smallpox appeared to be controllable by the new practice of vaccination. This all changed in the nineteenth century, raising concerns that inadequate attention to public health would interfere with ﬂourishing trade links and empire building. Between 1851 and 1938, 14 International Sanitary Conferences were held which laid the institutional foundations for fuller international health cooperation. Informed by developments in medical science, an International Sanitary Convention was agreed in 1892, setting out quarantine and hygiene practices. A total of four conventions were agreed by 1903, later codiﬁed and consolidated into the International Sanitary Regulations, the forerunner of the present-day International Health Regulations. In 1907, a permanent body based in Paris, the Oﬃce International d’Hygiène Publique (OIHP) was created to collect and report epidemiological data from its member states. However, the OIHP was pre-empted by the establishment of the Pan American Sanitary Bureau in 1902 (see below) for the Americas region. The next major institutional development in international health cooperation was the creation of the League of Nations Health Organization (LNHO) in 1920 after the First World War. It was agreed that the founding nations would “endeavour to take steps in matters of international concern for the prevention and control of disease.”4 The founders foresaw its role as going beyond the collection and reporting of epidemiological data, as per the OIHP, to include a more active role in disease control and prevention. The devastating 1918–19 inﬂuenza pandemic, which killed around 25 million people worldwide, punctuated the need for greater collective action. Perhaps more impressively, improvements in public health achieved through social reform, beginning in the mid-nineteenth century, pointed to the potential gains to be achieved through broader-ranging activities. The desire to expand the scope of international health cooperation, however, was overtaken by wider political developments which led to the notable absence of the United States from membership in the League of Nations. The coexistence of three major international health organizations led to considerable overlap and rivalry.5

History of international health cooperation

3

As well as intergovernmental cooperation, numerous nongovernmental organizations were founded during this period concerned with health activities. The League of Red Cross Societies (later the International Federation of Red Cross and Red Crescent Societies) was established in 1919 “in view of a worldwide crusade to improve health, prevent sickness, and alleviate suﬀering.”6 Consolidating an initiative that had begun in the 1860s by Swiss citizens providing humanitarian relief during times of war, the organization grew into a worldwide movement of national societies independent of governments. The Rockefeller Foundation’s International Health Commission (renamed the International Health Board in 1916) was founded in 1913 for the purpose of extending the work of the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease. In addition to hookworm, the Board’s early activities included the control of yellow fever, malaria and tuberculosis, public health education, virus studies and related research. In 1927, the Board was disbanded and its work was continued by an International Health Division. Key contributions to international health cooperation during this period were support for the establishment of schools of public health in the United States and abroad, and the development of a vaccine against yellow fever. Other notable charitable foundations with health interests created before the Second World War were the Ford Foundation (1936) and Wellcome Trust (1936). By the end of the twentieth century, the role of charitable foundations in health would grow signiﬁcantly, even to rival that of intergovernmental organizations.

Establishment of regional health organizations Along with the OIHP and LNHO, a number of regional health organizations were established with varying composition, functions and resources. The Conseil supérieur de Santé de Constantinople, dating from the Ottoman Empire of the late 1830s, was created to address the spread of plague through the adoption of quarantine measures. In 1840 the Conseil Sanitaire de Tanger was formed in Morocco to control the spread of epidemic diseases such as plague and cholera. In 1843, the Egyptian Quarantine Board was established in Alexandria to strengthen eﬀorts against imported epidemics, and later became the regional epidemiological bureau of the OIHP. In 1867 the Shah of Persia established the Conseil Sanitaire de l’Empire, which met irregularly to address public health matters. In Europe, the European Commission for the Danube, created in 1856, included a limited range of public health activities within its remit.7

4

History of international health cooperation

The most prominent regional health organization was the Pan American Sanitary Bureau (PASB, initially the International Sanitary Bureau), whose origins, and eventual integration into WHO, merit further description because of its inﬂuence on the latter’s structure and mandate. The origins of the PASB also lie with the International Sanitary Conferences of the nineteenth century. However, these conferences proved dissatisfying for some countries because of their strong European focus. While the ﬁrst four conferences focused on cholera, which did pose a serious threat on both sides of the Atlantic, yellow fever merited little attention despite being the main disease threat in the Americas. Among the participants to the 1881 conference held in Washington, DC was Carlos Finlay, the special delegate for Spain representing Cuba and Puerto Rico. He announced at the meeting a major scientiﬁc theory—the transmission of yellow fever by an intermediate agent, the mosquito Aedes aegypti (then called Stegomyia fasciata). Alongside the development of medical science was a growing movement towards inter-American health cooperation. In 1890 the First International Conference of American States, held in Washington, DC, had established the International Union of American Republics (today the Organization of American States) for the initial purpose of collecting and disseminating commercial information. The Second Conference, held in Mexico City in October 1901, recommended that the International Union call a “general convention of representatives of the health organizations of the diﬀerent American republics” to formulate “sanitary agreements and regulations” and to periodically hold health conventions. The general convention should also “designate a permanent executive board of not less than ﬁve members,” to be known as the “International Sanitary Bureau,” with headquarters at Washington, DC.8 The First General International Sanitary Convention of the American Republics, whose purpose was to assure eﬀective cooperation in promoting health in the Americas, was held in Washington, DC in December 1902 attended by 11 countries. The conference’s aim, to foster collective action against the spread of major disease threats in the region led to what was to become the oldest continuously functioning international health agency in the world, the PASB led by Chairman Walter Wyman. Like the OIHP and LNHO, the PASB’s initial mandate and resources remained limited. It was a small organization, dominated by the US Public Health Service, charged with rationalizing a complex set of quarantine regulations.9 Nevertheless, the PASB contributed to important work collecting epidemiological data and facilitating the exchange of information among its member states and other health organizations.

History of international health cooperation

5

An annual report summarized the known health conditions of member states. Over time, it took a more active operational role, for instance, by initiating a yellow fever eradication program. During the early 1940s, the Bureau continued to adapt its work to changing health conditions in its member states and public health needs of their populations. The decrease in incidence of cases and deaths due to quarantinable diseases continued. However, poliomyelitis was on the increase throughout the region; typhus and other rickettsial diseases were important problems in the Andean countries and Mexico; outbreaks of smallpox were reported in Argentina, Colombia, Mexico, and Paraguay; Chagas disease was a problem in most of the countries; two serious outbreaks of cerebrospinal meningitis had occurred in Chile and the United States in 1942; other problems included encephalomyelitis in Colombia, tick-borne relapsing fever in Bolivia, yaws in Ecuador, and measles in El Salvador and Nicaragua. The creation of other international agencies dealing with health prompted the Third Meeting of the Ministers of Foreign Aﬀairs of the American Republics, held in Rio de Janeiro, Brazil, in January 1942, to adopt two telling resolutions. First, the governments of the American Republics should take individually, or by complementary agreements between two or more of them, appropriate steps to deal with problems of public health and sanitation, by providing (in accordance with their ability) raw materials, services, and funds. Second, to those ends, they should use the technical aid and advice of the national health service of each country in cooperation with the PASB. This hemispheric recognition of the accomplishments of the Bureau presaged the zeal, shown some years later when the WHO was being created, with which the governments of the Americas defended the independence of the Bureau. Its dual role in serving also as the WHO’s Regional Oﬃce for the Americas embodied the ongoing tensions between independent regional bodies and the need for the WHO to provide cohesion and centralized leadership.

The rise of social medicine and public health The formation of regional health organizations was, in many ways, a boon for health cooperation. However, diﬀerences in mandates, institutional capacity and, perhaps most importantly, perspectives on how best to serve public health, proved divisive. While the International Sanitary Conferences signaled an unprecedented increase in health cooperation, their scope remained narrowly focused on selected epidemic diseases, notably cholera and, to a lesser extent, plague and

6

History of international health cooperation

yellow fever. The focus of the conferences on infectious diseases was understandable, given that half of all deaths in the late nineteenth century were believed to have been attributable to infectious diseases carried by water-, air- or food-borne vectors.10 Yet international action to address these diseases was also circumscribed, emphasizing surveillance and reporting, but little action on disease prevention, control or response. In other words, international health cooperation reﬂected the concerns of the major European powers, namely to prevent epidemic diseases from disrupting their political and economic interests at home and abroad. What was pointedly missing from the work of early international health organizations was attention to what would later become known as the broad determinants of health. The clear lessons from the social reforms of the nineteenth and early twentieth centuries were that the most substantial gains in health status and life expectancy could be achieved through improved housing, sanitation, nutrition and education. Of particular note was the recognized importance of addressing social inequalities. Stark disparities arising from rapid social and economic change during the Industrial Revolution left a signiﬁcant proportion of the population in western countries in poverty and want. The collection and dissemination of data on a limited number of diseases did little to address their plight. Building on the work of English pioneers of public health such as John Snow and Edwin Chadwick, along with French and German health and social reformers such as Jules Guerin, Alfred Grotjahn and Rudolph Virchow, social medicine evolved as a discipline seeking to understand how health, disease and social conditions are interrelated. Importantly, social medicine was not simply of scholarly interest. Its practitioners were also political reformers, radicals and activists who sought to change social conditions for the better. The most prominent early thinker in the development of social medicine was Virchow, a German pathologist who later developed the theory of cellular pathology. He was a committed social reformer who saw “politics [as] … nothing more than medicine on a grand scale.” For Virchow, the “physician was the natural advocate for the poor.” Medical historian George Rosen distills Virchow’s principles as follows: 1 Social and economic conditions profoundly impact health, disease and the practice of medicine. 2 The health of the population is a matter of social concern. 3 Society should promote health through both individual and social means.11

History of international health cooperation

7

During the ﬁrst half of the twentieth century, social medicine developed in many diﬀerent ways, challenging the biomedical paradigm that increasingly dominated the practice of modern medicine. As Porter writes, Virchow had articulated the need to develop a sociological method of inquiry into the conditions that maximized health and prevented disease. Inspired by the experiments in sociological medicine and social hygiene in revolutionary Soviet society in the 1920s, interwar sociomedical reformers on both sides of the Atlantic believed that the creation of a sociopolitical role for medicine could be achieved by turning it into a social science.12 Within Britain, social medicine contributed to policy debates on the creation of a free national health service as a fundamental social right. In the United States, social medicine gained a foothold at Yale University, where the Institute of Human Relations, created in 1931, sought to integrate medicine into research on social inequalities. The Great Depression of the 1930s reinforced interwar support for policies based on multifactorial analysis of health and disease. In Latin America, the work of Belgian doctor René Sand for the Rockefeller Foundation led to the creation of institutes of social medicine in Brazil and Peru. This work was supported by John D. Rockefeller, who believed that “[t]he best philanthropy is constantly in search of the ﬁnalities—a search for a cause, an attempt to cure evils at their source.” In 1945 an endowment by the Rockefeller Foundation led to the appointment of Sand as one of the ﬁrst professors of social medicine at Brussels University (see Box I.1). Internationally, as Porter describes, the governing committee of the League of Nations Health Organization prioritized the development of social medicine. The International Labor Organization’s representatives on the committee persistently argued that issues of social medicine could not be separated from the question of access to services that fundamentally aﬀected the health of workers. Before the Second World War, the International Health Committee of the Rockefeller Foundation also identiﬁed social insurance as a central issue of policy promotion.13 While the interwar period saw a ﬂourish of scholarly thinking and political support for the ideals of social medicine, by the end of the Second World War, stark geopolitics immediately overshadowed the international health policy agenda. At the national level, contrasting

8

History of international health cooperation

Box I.1

René Sand and social medicine

The Belgian doctor René Sand (1877–1953) is considered one of the pioneers of public health thinking and practice. In 1921, he joined the League of Red Cross Societies, of which he became secretarygeneral. In 1929 he founded and became the ﬁrst president of The International Hospitals Association. He served as secretary-general of the Belgian Ministry of Health beginning in 1937. After the Second World War he occupied the chair of social medicine at the University of Brussels (1945–52). He took a prominent part in the activities of the health section of the League of Nations and the World Health Organization. Sand’s greatest inﬂuence was, however, exerted by two important books, L’Economie Humaine par la Médecine Sociale (1934) and Vers la Médecine Sociale (1948). The second of these volumes is one of the most notable contributions made in our time to the philosophy of public health. The term “social medicine” requires some explanation to the American reader. It includes in its view not only the work of the physician and nurse, but that of the engineer, the physiologist, psychologist, the health educator, and all the other specialists participating in the public health program. He says, “In relation to the isolated individual, the art of preventing and curing disease is known as private medicine. In relation to the community as a whole, it is public medicine. In relation to those people and classes whose conditions call for special measures, it is social medicine.” The last two of these ﬁelds are commonly included in our deﬁnition of public health. In an inspiring series of chapters, Dr. Sand reviews the history of the medical profession and the hospital, of personal hygiene and public health, of “social hygiene,” of industrial medicine, of social assistance, of anthropology and psychology, and the history and the philosophy of “social medicine” in various countries. Dr. Sand received in 1951 the highest honor which can come to a public health worker in the international ﬁeld, the Leon Bernard Medal of the World Health Organization; but his best monument will remain for many years his notable book, The Advance to Social Medicine. Source: “Editorial: René Sand,” American Journal of Public Health 43, no. 11 (November 1953): 1476–77. www.ajph.org/cgi/reprint/43/11/1476

History of international health cooperation

9

theoretical perspectives on disease control and management shaped how public health developed as a discipline and practice across diﬀerent countries. In the United States, in particular, public health was deﬁned by a biomedical (therapeutic) model focused on the management of individual risk factors for chronic illnesses, an approach that continues to shape policy measures today. In Latin America, social medicine parted company with public health, thriving as a core part of eﬀorts to achieve social transformation based on Marxist social and political theory. In Europe, the growth of the welfare state included the creation of national health systems funded by social insurance schemes. Internationally, however, eﬀorts to reconcile social medicine and biomedicine in the creation of a WHO were subsumed within a rapidly emerging Cold War. In conservative circles within the US government, social medicine had a ring of “socialism,” and was closely associated with growing concerns about the rise of Communism. As well as strategic concerns about the inﬂuence of the Soviet Union, philosophical diﬀerences in beliefs about the appropriate roles of the state and market extended to deﬁning the mandate of the WHO. Fearing a repeat of the League of Nations, where the absence of the US membership left its Health Organization ineﬀectual, accommodation was sought. As we shall see in subsequent chapters of this book, this original tension between biomedicine, with its focus on individual behavior and biology, and social medicine, with its emphasis on understanding and transforming social conditions underlying health and disease, has shaped the WHO’s mandate, organizational structure and activities over the past six decades.

Outline of the book As the WHO celebrates its sixtieth anniversary in 2008, this book oﬀers a timely account of its unique role in international health cooperation. For the layperson, medicine is a highly specialized scientiﬁc endeavor, guided by universally shared values and, at least ideally, apolitical in its practice. Indeed, the modern-day version of the Hippocratic Oath, known as the Declaration of Geneva (1948), contains the phrase, “I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient.” From its beginnings, however, the WHO has been caught between this idealized vision and realpolitik. The WHO is concerned with “health” in its broadest sense, which immediately locates its mandate within a wider social context. Moreover, the universal value placed on

10

History of international health cooperation

good health has been confused with consensus on what causal factors most inﬂuence individual and population health status, how society should seek to address them and, given limited resources, what healthrelated goals should take priority. Advances in scientiﬁc knowledge, which have extended the realms of the possible in terms of extending life expectancy and quality of life, have only made such value-based choices more diﬃcult. It is for these reasons that health policy debates have been among the most politically heated. This book is not an attempt to assess the WHO against an idealized, and somewhat disputed, vision of medical science and practice. Indeed, this perception of medical professionals and the WHO largely explains its neglected analysis for much of its history. Rather, it begins with recognition of international health cooperation as invariably valuebased in its subject matter and operating context. For some, this is arguably lamentable.14 This book, however, takes the politics of international health cooperation as given, locating the organization within a complex landscape of often competing ideas, interests and institutions.15 In this sense, the WHO is assessed for its capacity to negotiate, and importantly mediate, the politics of international health. Chapter 1 discusses the creation of the WHO and deﬁnition of its mandate after the Second World War. The embedding of social medicine in the organization’s Constitution, amid strong pressures to more narrowly focus on biomedical interventions, is described. Of particular note was the post-war casting of the new organization as part of a group of institutions seen by functionalists as contributing to world peace through the provision of basic needs. Functionalists, led by David Mitrany,16 argued that the fulﬁllment of the so-called “wealth– welfare dimension of world politics” can unite peoples across state boundaries because of a natural harmony of such interests. Health was seen as a core component of this dimension, falling within the realm of “low politics,” where the interests of nation states could be enhanced through international cooperation rather than competition. In contrast, “high politics” concerned the maintenance and pursuit of core values and the self-preservation of the state. Functionalists believed that the WHO, through the promotion of international health cooperation, would serve as one of the foundations of peace and security. As shown in Chapter 1, this supposed location of the WHO within the realm of low politics rather than high politics deﬁned the expectations placed on the organization. The basic structure of the WHO, and its three institutional levels, is set out in Chapter 2. While its key governance mechanisms have remained unchanged, its range of programs and the relative balance

History of international health cooperation

11

among them has been subject to ongoing revision. This chapter also discusses the WHO’s membership and budget, both of which have been subject to political inﬂuences within and outside of the organization. Chapter 3 describes selected disease-focused activities of WHO which, some argue, should be the focus of the organization’s work. Beginning in the 1950s with the Malaria Eradication Programme, the WHO has initiated a succession of “vertical” programs. While there have been important successes, notably the eradication of smallpox in 1979, debates about the relative merits of vertical versus horizontal programs have endured throughout the organization’s history. The corresponding eﬀorts by the WHO to tackle the broad determinants of health, the social factors that underpin health and disease, are then addressed in Chapter 4. Although seen as breaking new ground, the WHO was revisiting social medicine. In doing so, the organization sought to challenge powerful political and economic interests, thus opening itself to accusations of going beyond its formal mandate, and even politicization. In Chapter 5 the book concludes with an examination of the pressures on the WHO to adapt to an increasingly globalized world. Since the 1990s, there have been major changes to the organization’s operating environment. The intensiﬁcation of ﬂows of people and other life forms; capital, goods and services; and information, knowledge and ideas across the world, known broadly as globalization, has renewed debates about the WHO’s mandate in international health cooperation (between member states). In addition, such ﬂows have raised questions about the need for global health cooperation which addresses health needs that cannot be dealt with by state institutions alone. The intersection of health issues with economic, trade and security policy, for example, has led the public health community to engage with key sectors. The creation of new global health initiatives, arising in part from broader ideological debates about the appropriate role of the state and market, as well as dissatisfactions with the traditionally state-centric WHO, has seen new institutional players come into greater prominence. These include non-state actors such as private companies, charitable foundations and civil society organizations (CSOs). Some of these new players have been better resourced, both economically and politically, while others boast rival expertise on speciﬁc health issues. Amid this transition from international to global health cooperation, more than ever the WHO faces profound questions about its future role.

1

Creation of the World Health Organization

The origins of international health cooperation, focused in the nineteenth century on furthering the economic and trade interests of the Great Powers, but broadening during the twentieth century to embrace broader political debates about the role of the state in providing for social welfare needs, invariably inﬂuenced the conception and birth of the WHO. Its inheritance of pre-existing institutions, both international and regional, also served to deﬁne its mandate and membership. From these beginnings, the WHO remained ﬁrmly embedded with the political and economic events of the post-Second World War period.

Post-war politics and international health cooperation As many parts of the world lay in ruins at the end of the Second World War, world leaders agreed to convene a conference to discuss the creation of an institution that would bring together various existing regional and international health organizations. An organization to deal with health cooperation would seem an obvious priority for the architects of a post-war order. The devastating inﬂuenza pandemic that followed the First World War was a clear historic lesson of the need for eﬀective cooperation between governments after major conﬂicts. Large-scale movements of populations during and after the Second World War, many of whom lacked basic housing, food and health care, led in some cases to the spread of infectious disease organisms and vectors. The destruction of physical and economic infrastructure also weakened the capacity of many governments to respond to health needs. For example, dengue increased in Southeast Asia during and immediately after the war, as a result of the spread of mosquitoes and diﬀerent virus strains throughout the region.1 Similarly, a resurgence of sexually transmitted diseases was reported to have occurred among troops after

Creation of the World Health Organization

13

both world wars.2 The signiﬁcant health challenges facing governments indicated a clear need for collective international action. It is perhaps curious, therefore, that the task of creating a world health organization was not part of the original agenda of the UN Conference on International Organization held in San Francisco in April–June 1945. In the immediate aftermath of war, the focus of attention was instead placed on emergency relief. Urgent health care was provided by such organizations as the UN Children’s Emergency Fund (UNICEF), created in 1946, and UN Relief and Rehabilitation Administration (UNRRA), founded in 1943 to give aid to areas liberated from the Axis powers. Fear of new post-war epidemics prompted the Allied countries to draw up plans for action. At its ﬁrst meeting in 1943, UNRRA put health work among its primary and fundamental responsibilities. The neglect of health cooperation at the UN conference prompted the Brazilian and Chinese delegations to argue that “medicine is one of the pillars of peace.” The two delegations submitted a joint declaration recommending “a General Conference be convened within the next few months for the purpose of establishing an international health organization.” The UN Economic and Social Council agreed in February 1946 that an International Health Conference would be convened in New York later that year “to consider the scope of, and the appropriate machinery for, international action in the ﬁeld of public health and proposals for the establishment of a single international health organization of the United Nations.”3 The responsibility for preparing for this conference was given to a Technical Preparatory Committee consisting of 16 “experts in the ﬁeld of international health,”4 chaired by René Sand. Almost all were ministers of health or senior public health oﬃcials in their respective countries. The committee met in Paris during March–April 1946 to “prepare an annotated agenda and proposals for the consideration of the Conference,” including a draft constitution and various accompanying resolutions. Detailed proposals were submitted by delegates from individual countries, notably France, the United Kingdom and the United States, serving in an individual capacity, along with submissions from existing health organizations. In this way, the Committee drafted proposals on key aspects of the organization’s mandate, governing structure, administration and ﬁnancing. The committee left two issues for resolution at the conference itself: where to locate the headquarters and, more challengingly, whether regional organizations would be associated or fully integrated with the new organization. The latter question, as discussed below, would remain an issue of ongoing debate for many years.

14

Creation of the World Health Organization

In June 1946, the International Health Conference opened as the ﬁrst conference to be held under the auspices of the UN. The conference was attended by all 51 members of the UN, as well as 13 non-member states, the Allied Control Authorities for Germany, Japan and Korea, and observers from relevant UN bodies. Signiﬁcantly, existing international health organizations such as the OIHP were invited to attend in a consultative capacity. Over the next four and a half weeks, the conference agreed on the new organization’s constitution, a protocol for the dissolution of the OIHP, and the setting up of an Interim Commission to assume the health-related duties of the LNHO and UNRRA until the WHO could be formally established. Once again, unexpectedly, there was a further delay in the formal establishment of the WHO as founders awaited receipt of the twentysixth signature of ratiﬁcation of the Constitution by a member state. The two-year interval between the conclusion of the International Health Conference and establishment of the organization was unforeseen by those keen to see the new agency begin its work. The main reason for this delay was the onset of the Cold War, which dampened post-war internationalism, and led to debates about the appropriate role for the UN. Within international health, rising tensions between the United States and the Soviet Union brought into relief fundamental philosophical and ideological perspectives about the determinants of health and disease. This brought into greater relief the schism between those who envisioned an organization that embraced the values and goals of social medicine, and those who sought to circumscribe its mandate to, for example, disease surveillance and control. As described in the introduction to this book, social medicine was viewed suspiciously by a US government already preoccupied with the perceived geopolitical threat of the Soviet Union, dampening enthusiasm for a strong institution with a wide-ranging mandate. The United States was also ﬁercely protective of the independent status of Pan American Health Organization (PAHO, see below), and did not favor its subordination to another institution. This delay in the formal creation of the WHO placed responsibility for maintaining international health cooperation on the Interim Commission. Its capacity was challenged almost immediately by a severe cholera outbreak in Egypt, increasing from three cases on 22 September 1947 to around 33,000 cases a month later in widely separated areas on both sides of the Red Sea and the Suez Canal. The Commission made an immediate plea for large amounts of vaccine, resulting in 20 million doses being ﬂown to Cairo from the United States, the Soviet Union, India and elsewhere, one-third provided as

Creation of the World Health Organization

15

donations. While the epidemic eventually claimed over 20,000 lives by February 1948, it prompted a surge in the number of countries ratifying the WHO Constitution. The WHO Constitution came into force on 7 April 1948 (celebrated every year since as World Health Day) and the WHO came into formal existence in September 1948 as the UN specialized agency for health. Canadian Brock Chisholm, who served as one of 16 international experts consulted in drafting the agency’s ﬁrst Constitution, was elected as the WHO’s ﬁrst Director-General (see Box 1.1). The ﬁrst World Health Assembly (WHA), the WHO’s plenary body, was convened in June 1948.

Box 1.1

Brock Chisholm as the ﬁrst WHO Director-General

George Brock Chisholm (1896–1971) became WHO’s ﬁrst Director-General in 1948. Born in Canada, Chisholm served in the First World War before returning home to earn his medical degree from the University of Toronto in 1924. He then interned in England where he specialized in psychiatry. After six years in general practice in Ontario, he attended Yale University where he specialized in the mental health of children. At the outbreak of the Second World War, Chisholm rapidly rose within the Canadian military and government. He joined the war effort as a psychiatrist dealing with psychological aspects of soldier training before rising to the rank of DirectorGeneral of the Medical Services, the highest position within the medical ranks of the Canadian Army. He was the ﬁrst psychiatrist to head the medical ranks of any army in the world. In 1944, the Canadian Government created the position of Deputy Minister of Health. Chisholm was the ﬁrst person to occupy the post and held it until 1946. The same year Chisholm also became the Executive Secretary of the Interim Commission of WHO. He served as one of 16 international experts consulted in drafting the agency’s Constitution. As a committed internationalist, he was strongly committed to fostering collective health action across countries. This was demonstrated by the Egyptian cholera epidemic of 1947–48 during which he successfully facilitated efforts between Egypt and its neighbors to prevent the spread of the disease, including quarantine precautions. International aid to supply vaccines was also effectively mobilized.

16

Creation of the World Health Organization In 1948 Chisholm was elected as WHO’s ﬁrst Director-General on a 46–2 vote. His own beliefs, that ill health was attributable to the shortcomings of human beings rather than biomedical factors, strongly inﬂuenced his tenure. He famously stated, “The world was sick, and the ills from which it was suffering were mainly due to the perversion of man, his inability to live at peace with himself. The microbe was no longer the main enemy; science was sufﬁciently advanced to be able to cope with it admirably. If it were not for such barriers as superstition, ignorance, religious intolerance, misery and poverty.” He was especially moved by reports of the health consequences resulting from the atomic bombs dropped on Nagasaki and Hiroshima. In addition, Chisholm stressed the need to give attention to the importance of both physical and mental health. This belief is reﬂected in the broad deﬁnition of health within WHO’s Constitution. Refusing re-election, Chisholm remained Director-General until 1953 when he was succeeded by Marcolino Candau. Source: Compiled from Allan Irving, Brock Chisholm, Doctor to the World (Markham: Fitzhenry and Whiteside, 1998)

Deﬁning the mandate of the WHO Yves Beigbeder deﬁnes a specialized agency as “one which conducts a programme of importance for the United Nations, in a speciﬁc ﬁeld of competence, under the general review of the General Assembly and of the Economic and Social Council, but with important scope of autonomy in matters of membership, programme, personnel and ﬁnances.”5 Setting out the WHO’s mandate as the UN specialized agency for health was a core task of its creators. The organization’s overall goal, as deﬁned in Article 1 of its Constitution, is “the attainment by all peoples of the highest possible level of health.” The lasting legacy of Brock Chisholm, René Sand and other advocates of social medicine was the adoption, in the WHO’s Constitution, of a broad deﬁnition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or inﬁrmity,”6 a reﬂection of the desire of many of its founders for the WHO to go beyond the biomedical focus of its institutional predecessors. Moreover, health is recognized within the document as “one of the fundamental rights of every human being,” and governments are responsible “for the health of

Creation of the World Health Organization

17

their peoples.” To fulﬁll its overall goal, the WHO is tasked with 22 functions, beginning with acting as “the directing and coordinating authority on international health work,” and ending with taking “all necessary action to attain the objective of the Organization.”7 In this way, the WHO embodied the aspirations and principles of social medicine with its broad and inclusive vision of health development and cooperation. This vision of the WHO’s mandate was viewed with some suspicion by those who equated the goal of social equity with the spread of postwar Communism. While this perceived association was erroneously simplistic, advocates of social medicine were clearly located on a different point in the political spectrum to those advocating a restricted role for government in the health sector. This diﬀerence led to fundamentally diﬀerent perspectives about what goals should underpin international health cooperation and, by extension, what the WHO’s mandate should be. Advocates of a more circumscribed role, albeit not as limited as the collection and dissemination of data on selected disease outbreaks carried out by the LNHO and OIHP, favored a diseasefocused mandate. Seeking to avoid a repetition of the notable absence of the United States from the League of Nations, and thus participation in its Health Organization, combined with the immediate need to address urgent health needs during the post-war period, the biomedical perspective prevailed during the ﬁrst period of the WHO’s history. The initial priorities included initiatives to address malaria, tuberculosis, sexually transmitted diseases, parasitic diseases, and viral diseases. More broadly, nutrition, maternal and child health, environmental sanitation, public health administration and mental health were also given attention. As described in Chapter 3, the WHO’s eﬀorts to tackle speciﬁc diseases yielded mixed success. One important task for the WHO during its early years was the revision and consolidation of the International Sanitary Regulations, which were deemed to be “largely ineﬀective … [and] hampered inter alia by a lack of consistency and uniformity in their implementation.”8 In part, this was due to much of the work of the OIHP and the League’s health units being cut short by the war, although infectious disease surveillance and reporting (published in the Weekly Epidemiological Record) continued. The WHA sought “strong limitations on the right of States to formulate reservations [which] would have guaranteed uniformity in a technical area of crucial public health importance.” In May 1951, the International Sanitary Regulations, renamed the International Health Regulations (IHR) in 1956, were adopted by the WHA (Resolution WHA4.75). The IHR (1951) was a revision and

18

Creation of the World Health Organization

consolidation of the recommendations of the preceding 13 International Sanitary Conventions. Plague, cholera, yellow fever, smallpox, typhus and relapsing fever are identiﬁed as “quarantinable diseases.” Importantly, unlike previous recommendations, the regulations are binding on all member states unless a country chooses to “opt out.” Article 22 of the WHO’s Constitution states that “Regulations adopted pursuant to Article 21 shall come into force for all Members after due notice has been given of their adoption by the Health Assembly except for such Members as may notify the Director-General of rejection or reservations within the period stated in the notice.” Article 22 was one of the most-debated during the drafting of the Constitution, as it was perceived by some delegations as an infringement of state sovereignty. Nonetheless, such powers to adopt binding regulations were agreed in ﬁve speciﬁc areas, including “sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease,” a reﬂection of the recognized importance of such measures for eﬀectively protecting public health. While the above work enabled the WHO to maintain a relatively low-key UN organization during its ﬁrst years, carrying out what were seen as largely technical activities, support for tackling the social factors inﬂuencing health and disease was never far from the surface. For those seeking to deﬁne the WHO’s mandate broadly, in line with its Constitution, the early years were a cautious beginning. Tensions between the two perspectives cause ongoing debate, both within and outside the organization. Adding weight to the need to broaden the scope of the WHO’s work was the growing number of WHO member states. From the early to mid 1950s, as many newly independent countries joined the organization, the degree and nature of the WHO’s involvement in “technical assistance” became a subject of discussion. What functions could and should the WHO play in assisting developing countries to build their health systems? One commonly held view is that, given limited resources, the WHO should restrict itself to so-called “normative activities,” such as setting standards, agreeing nomenclature and establishing clinical guidelines. This is reﬂected in the WHO’s role to propose conventions, agreements and regulations, and make recommendations about international nomenclature of diseases, causes of death, and public health practices. It also develops, establishes and promotes international standards concerning foods and biological, pharmaceutical and similar substances. Such work would largely take place at the headquarters and regional levels. Member states (ministries of health), other international organizations, nongovernmental organizations and bilateral

Creation of the World Health Organization

19

donor agencies, in turn, could draw on this normative work to guide their health development activities. For example, the WHO might put forth recommendations on vaccination for children under ﬁve years of age—diseases to be vaccinated against based on accumulated data on disease risks; clinical guidelines on route of administration, vaccination schedule and dosage; and information on safety and contraindication. Operational organizations, such as UNICEF, would seek to use such guidelines to support ministries of health to carry out immunization programs in their countries. UNICEF may provide funds to do such work or even carry out the vaccinations itself through appointed staﬀ. In this way, the WHO does not implement its own recommended policies but rather enables other organizations to do so. This circumscribed mandate for the WHO, however, was criticized by some as an artiﬁcial separation of normative and technical activities. Could the WHO achieve its normative activities without engaging in some degree of technical work? Normative (global level) activities also implied a one-way or “top down” learning process, ignoring how country-level activities can directly feed into the development of normative work. Moreover, the low-proﬁle, normative work of the WHO was threatened to be overshadowed by other UN organizations, notably UNICEF and United Nations Development Programme (UNDP, created in 1969), as they became more active in the health sector from the 1960s. As described in Chapter 4, such comparisons would become more intense during the 1980s and 1990s as pressure was put on UN organizations by major donor countries to demonstrate their “value for money.” The WHO’s normative role, often out of the spotlight, began to receive unﬂattering assessments with more high-proﬁle organizations. At times unﬂattering comparison with other UN organizations has remained a sore point for the WHO to the present day. In 2001, within the context of accelerating processes of globalization, then DirectorGeneral Gro Harlem Brundtland defended the need for the WHO to be selective in its endeavors. Her successor, Lee Jong-wook, made a deliberate attempt to raise the proﬁle of the WHO by becoming more involved in the implementation of health interventions. In 2003 he launched the 3 by 5 Initiative, “to provide three million people living with HIV/AIDS in low- and middle-income countries with lifeprolonging antiretroviral treatment (ART) by the end of 2005.” The extent to which this was successfully achieved is discussed in Chapter 4, but it illustrates the pressure felt by consecutive leaders to reﬂect on the WHO’s mandate within a changing world. Since the 1980s, ﬁnancial resources have become increasingly constrained, intensifying discussion of whether the WHO should maintain

20

Creation of the World Health Organization

a broad menu of activities, growing over time and spreading resources thinly. Or should it concentrate on certain strategic activities that make more impact in fewer areas? Should the WHO focus its resources at certain levels—global, regional or country level? As an expression of this starting point, and in fulﬁllment of the 22 functions listed in the Constitution, the WHO’s work program and structure grew steadily in breadth and depth. Over time, and in response to invariable limits on budgetary resources, questions about the appropriate mix of activities undertaken by the WHO have been regularly raised. The current debate focuses on the identiﬁcation of “core functions” of the WHO compared with those of other global health initiatives. These might include: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalyzing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends. These core functions were set out in the Eleventh General Programme of Work, which provides the framework for an organization-wide program of work, budget, resources and results. Entitled “Engaging for Health,” it covers the ten-year period from 2006 to 2015. The process of setting the Eleventh General Programme of Work9 reﬂected the ongoing challenge of deﬁning the WHO’s mandate. The program is intended to provide “a long term perspective on determinants and trends in health,” and a broad strategic framework to guide the work of member states, partner organizations and the WHO secretariat. The draft program, however, immediately met with concerns among Executive Board members that it focused on the global health agenda rather than what the WHO would be doing. A major rewrite of the Programme was undertaken in 2006, along with an eﬀort to establish clearer priorities by reducing the number of priority areas set out in the budget for the medium-term strategic plan (MTSP) from 36 in 2006–7 to 16 for 2008–9. This is accompanied by a more robust set of indicators, agreed by an external group of health measurement and statistics experts, to monitor the achievement of

Creation of the World Health Organization

21

agreed objectives. In this way, it is believed that the plan will “enable the WHO to respond in a ﬂexible and dynamic manner to a changing international health environment.”10 Ongoing debate about the WHO’s mandate, whether expressed in terms of social versus biomedicine, normative versus technical (operational) activities, or as priority setting amid limited resources, has remained a deﬁning feature of policy debates within the organization. Diﬀerent views about what the WHO should do have been ascendant and descendant over the past six decades. As Roger Bate writes, The early belief of the organization was that endemic, preventable, and treatable diseases should be attacked through national and international initiatives to interrupt the transmission of the infection, while the remaining, much smaller number of cases should be dealt with through the gradual development of community-based primary care facilities. But rather than coordinating these two approaches to achieve optimal results, factions emerged within the WHO that at diﬀerent times favored one approach to the exclusion of the other. Many who should have known better had unrealistic expectations for both approaches.11

Who’s in and who’s out: human rights versus power politics The universalism implied by the recognition of health in the WHO’s Constitution, as “one of the fundamental rights of every human being,” has faced considerable obstacles in its pursuit. Thus, membership of the WHO is open to all member states of the UN, based on the belief that international health cooperation requires all countries to participate. In consideration of the number of colonial territories that still existed after the Second World War, associate membership was extended to “territories or groups of territories which are not responsible for the conduct of their international relations.” In 1948 the WHO had 55 member states, growing to 193 in 2007, including all UN member states except Liechtenstein, and 2 non-UN members (Niue and the Cook Islands). Territories that are not UN member states may join as associate members (with full information but limited participation and voting rights) if approved by an Assembly vote: Puerto Rico and Tokelau are associate members. Entities may also be granted observer status—examples include the Palestine Liberation Organization and the Holy See (Vatican City). Formally, UN members can join the WHO by unilateral, formal notiﬁcation to the UN Secretary-General that they accept the WHO Constitution. A non-UN member may be

22

Creation of the World Health Organization

admitted if its application is approved by a simple majority vote of the WHA. Territories or groups of territories “not responsible for the conduct of their international relations” may be admitted as associate members upon application by the authority responsible for their international relations. Even during the International Health Conference of 1946 to draft the WHO’s Constitution, the principle of universality was a point of dispute. While the Technical Preparatory Committee supported the proposal that membership should be open to all states, the UN Economic and Social Committee (ECOSOC) adopted a resolution on 11 June 1946 that, “in the struggle against disease and particularly endemic disease … the competent authority of the UN should regulate admission to membership.” In eﬀect, this left the WHO subject to politically motivated wrangling, originating from outside the health sphere, over the membership of certain countries. The ﬁrst major dispute arose over the withdrawal of membership by Eastern bloc countries in 1949. Membership by the Soviet Union was resumed in April 1957, followed shortly afterwards by other Eastern bloc countries. A related issue was the admission of the Soviet-allied portion of the “divided nations,” namely North Korea, East Germany and North Vietnam. The United States, United Kingdom and France opposed their membership in the UN, including the WHO.12 At the fourteenth WHA, a Soviet-supported resolution on universal membership led to heated debate and eventually a compromise recognition that countries that could become WHO members, and had the right to do so, should give consideration to joining the organization. Disagreement over the occupation of the “China seat” in the WHO has also been an extension of wider geopolitics. Since the defeat of the Nationalist Kuomintang by the Communist forces in 1949, leading to the establishment of the People’s Republic of China, representation of China in the UN has been a subject of dispute. In May 1950, Taiwan announced its withdrawal from WHO membership in line with its nonmembership in other UN organizations. In line with other UN organizations, the People’s Republic of China (PRC) was granted China’s “seat” at the WHO in 1972, leading to the corresponding withdrawal of the Republic of China (Taiwan) from membership. Since 1997, Taiwan has unsuccessfully applied for WHO observer status under the term of “health entity,” hoping to emphasize practical rather than political considerations. Its annual request has been generally supported by Japan and the United States. In 2007, the request was upgraded to full membership on the basis that the country required access to the Global Outbreak and Alert Response Network. Taiwan

Creation of the World Health Organization

23

was at the epicenter of the Severe Acute Respiratory Syndrome (SARS) outbreak in 2002–3, and would likely be at the front line of a potential human inﬂuenza pandemic. President Chen Shui-bian described exclusion from the Global Outbreak and Alert Response Network as “inhuman and unjust.” Despite these arguments on technical grounds, in May 2007 the WHA declined to include Taiwan’s proposal on the conference’s provisional agenda. The PRC continued to assert that Taiwan is “an inalienable part of China.” The Chinese Minister of Health aﬃrmed that “Although the reuniﬁcation of the mainland and Taiwan has yet to be achieved due to historical reasons, the fact that the mainland and Taiwan both belong to one China will never change.”13 A similar intransigence arose over health cooperation with Israel. In 1951 Arab League states decided not to cooperate with Israel in the Eastern Mediterranean region. Without such cooperation, the regional oﬃce’s annual sessions were cancelled until 1954. Two subcommittees were established in an eﬀort to resolve the dispute, and eventually Israel was moved to the European Regional Oﬃce. Ongoing tensions in the region, nonetheless, have continued to complicate membership issues. In 1989, the Palestinian Liberation Organization (PLO) applied for full membership of the WHO. Arab countries oﬀered to end their calls for the suspension of Israel from another specialized agency, the International Telecommunication Union (ITU). As described in the New York Times, The P.L.O. has chosen the health organization as the ﬁrst United Nations body to petition for membership because it is the easiest one to join, with only a simple majority required. … Diplomats believe that admission to the World Health Organization would represent a major triumph for the P.L.O. in its campaign to win recognition as the representative of the Palestinian state it declared last year. Membership in the health organization would probably also result in the upgrading of the P.L.O.’s observer mission at United Nations headquarters in New York. As a member of a specialized United Nations agency, the P.L.O. would be entitled to call its New York presence the observer mission of a non member state—giving it a status at the United Nations like those of Switzerland and the Vatican—as opposed to its present status of observer mission of an organization.14 The application opposed by Israel, the United States and the European Community, a decision was put oﬀ for one year, cushioned by an oﬀer of increased medical aid to Palestinians living in the Israeli-occupied

24

Creation of the World Health Organization

territories administered by the International Committee of the Red Cross (ICRC). The following year, the WHA voted to indeﬁnitely defer the application, under the shadow of threats by the US government to withhold its substantial ﬁnancial contributions.15 Thirty-eight US senators, led by Republican Robert Kasten, wrote to Secretary of State James A. Baker warning that they would consider “‘a range of punitive action’ against any UN agencies that recognized Palestine. The American Assistant Secretary of State for International Organization Aﬀairs, John Bolton, described the application as ‘fundamentally illegitimate’ and added that WHO has, hopefully, ﬁnally rid itself of the matter.”16 The issue was far from resolved, however. In 1998 the UN General Assembly’s granting of observer status to Palestine prompted similar action by the WHA. In May 2000, the WHA adopted a resolution which “decides to confer upon Palestine in the World Health Assembly and other meetings of the World Health Organization, in its capacity as an observer, the rights and privileges described in the Annex to the aforementioned resolution of the United Nations General Assembly.”17

Conclusion The conception, birth and formative years of the WHO were shaped by two strong and, at times, opposing inﬂuences. The ﬁrst were the public health experts of the Technical Preparatory Committee who envisioned an organization of universal membership, acting to address the world’s physical and mental health needs through a broad range of collaborative activities. The organization was to be guided by the values of social equity and internationalism, serving humanitarian rather than selfinterested goals. The WHO’s Constitution, emphasizing health as a human right, has been the most lasting legacy of this perspective. The second inﬂuence came from those who located the WHO ﬁrmly within the geopolitics of the Cold War. In this context, the organization was expected to enhance international health cooperation, but within a conﬁned range of activities. Health needs were largely deﬁned in terms of diseases, notably epidemic infectious diseases, and the organization was expected to focus its eﬀorts on controlling disease agents and supporting the delivery of scientiﬁc and technical interventions. The WHO remained subordinate to the UN as a whole, and eﬀorts to place health goals above power politics were pointedly rejected. As shown in subsequent chapters, these two visions of the WHO would be an ongoing source of tension.

2

Structure and functions

The basic institutional structure and functions of the WHO were a reﬂection of eﬀorts by its creators to forge a new organization, as a core part of the post-war order, from new aspirations for more concerted international health cooperation, and pre-existing health bodies and their political constituencies. Of particular importance was the need to unite the latter, as part of this new endeavor, through clear leadership and unrivalled technical expertise. The result was a threetiered organization which, in principle, enabled the WHO to combine centralized policy leadership with decentralized operational capacity. In practice, the appropriate distribution of staﬀ, ﬁnancial resources and, perhaps most importantly, decision-making power across the headquarters, regional and country levels has remained an ongoing source of tension.

World Health Assembly The main components of the WHO’s organizational structure have remained unchanged since its formal establishment in 1948. The organization’s supreme decision-making body is the WHA. The WHA meets annually, usually in May, to determine the overall policy direction of the WHO’s six-year General Programme of Work, review and approve reports and activities of the Executive Board (see below), and review and approve the annual budget, among other things. It also appoints the Director-General (for ﬁve-year terms) and elects the 34 members of the Executive Board (see below). Delegations of member states consist of not more than three delegates most qualiﬁed in their technical competence in the ﬁeld of health, preferably representing the national health administration. Representatives of other relevant international organizations and oﬃcially recognized nongovernmental organizations (NGOs) are permitted to attend as observers.

26

Structure and functions

In carrying out its work, the WHA is assisted by a number of committees with speciﬁed responsibilities, such as the Committee on Administration, Finance, and Legal Matters and the Committee on Programme and Budget. The WHA also holds the authority to adopt regulations in such ﬁelds as sanitary and quarantine requirements; nomenclature for diseases, causes of death, and public health practices; and standards with respect to the safety, purity and potency of biological, pharmaceutical and similar products. As discussed in Chapter 1 in relation to the IHR, regulations are binding unless member states choose to opt out of them. In principle, the WHA is the WHO’s plenary body where all member states are represented. Decisions are formally governed by the principle of “one state, one vote,” thus giving all countries, regardless of their size and power, an equal say in decision-making matters. In practice, the majority of WHA decisions are not subject to voting but are agreed by consensus and presented as recommendations (i.e. resolutions). Moreover, important and perhaps key decisions about priority setting may take place elsewhere, such as the Executive Board, Secretariat or even particular member states through their decisions to provide additional earmarked funding for designated purposes. The variable technical capacity of member states also means that there are inequalities in the ability to inﬂuence the policy process.

Executive Board The Executive Board (EB) of the WHO oversees the implementation of decisions taken by the WHA. In 1948, the EB consisted of 18 members. By 2007, as a reﬂection of the WHO’s increased membership, this number had risen to 34. While member states are elected by the WHA to propose EB members, persons selected are expected to serve in an individual capacity as “technically qualiﬁed in the ﬁeld of health” rather than as representatives of particular governments. EB members serve for three-year terms, and each year one-third of EB members is changed. The EB meets twice each year, in January and after the WHA in May. Among its main responsibilities are preparing the agenda for the WHA, giving eﬀect to WHA decisions, submitting a draft General Programme of Work, reviewing the proposed program budget, advising on questions of a constitutional and regulatory nature, submitting advice or proposals on its own initiative, taking emergency measures regarding the WHO’s ﬁnances and functions, and performing any other functions entrusted to it. As with the WHA, there are committees to

Structure and functions

27

assist in this work. Member states may respond within a year to proposals put forth by the EB, in the form of a report to the WHA.

The Secretariat The Secretariat is the administrative and technical organ of the WHO, responsible for implementing the organization’s activities. It consists of the headquarters in Geneva, 6 regional oﬃces, and 147 country and liaison oﬃces (see below) in selected member states. The Secretariat is headed by the Director-General, who is nominated by the EB and conﬁrmed by the WHA for a ﬁve-year term (renewable for a further term). Among the primary responsibilities of the Director-General, as chief technical and administrative oﬃcer, are the appointment of Secretariat staﬀ, preparation of annual ﬁnancial statements, and the drafting of the proposed program budget. Since 1948, there have been seven Directors-General, all of whom have been medically qualiﬁed. After much discussion at the International Health Conference in 1946, it was agreed to locate the Headquarters in Geneva, Switzerland at the former site of the Health Organization of the League of Nations. From here, under Director-General Chisholm, the organization established a decentralized structure, establishing and linking the three tiers of headquarters, regional and country oﬃces into a single institution. Today, the daily work of the WHO is carried out by around 8,500 technical and support staﬀ, distributed across the three levels of the organization, with technical staﬀ dominated by medical professionals. Within this basic structure, over the past 60 years, the speciﬁc programs within the Secretariat have been subject to ongoing change to reﬂect shifts in strategic focus and available resources. During his twenty years as Director-General (1953–73), Marcolino Candau (Box 2.1) expanded the scope of the WHO’s work considerably to reﬂect the broad deﬁnition of health within its Constitution. Under Halfdan Mahler (1973–88) (see Box 4.1) and Hiroshi Nakajima (1988–98), the organization continued to take a “full menu” approach to programming. When questioned whether the WHO should be all things to all member states, or be more selective in its focus, Nakajima pointed to the role of member states in priority setting: We are dealing in a very strange world. For example, the United States says oral health is a low priority. This year there was World Oral Health Day—it was not me, it was the member states who recommended this—and the Japanese dental association held a huge international congress of oral health. This is because in Japan

28

Structure and functions the elderly population is rapidly increasing, and dental health is becoming a very serious problem despite the decline in dental caries. Why does the United States say oral health is not a priority for WHO? Maybe because if dental services are included in America’s new health plan it is economically not feasible. That is my understanding. The same country says that cancer is not a priority for WHO, but for my country cancer is a priority.1

Box 2.1

Marcolino Gomes Candau

Marcolino Candau (30 May 1911–23 January 1983) was the longest serving Director-General in the WHO’s history, elected in 1953 and remaining in ofﬁce until retiring in 1973. He was born in Rio de Janeiro, Brazil and, after training as a public health doctor, worked for 17 years in the Brazilian Public Health Service, largely as a malariologist. During this period, he worked with Fred Soper on a Rockefeller Foundation-funded project to eradicate the mosquito, A. gambiae. With proven organizational skills, he joined the WHO in 1950 as director of the Division of Organization of Public Health Services. He progressed quickly, becoming Assistant Director General in charge of advisory services within a year. Then, in 1952 Candau was named Assistant Director of the regional ofﬁce for the Americas, the Pan American Sanitary Bureau in Washington, DC. The following year, he was elected as the WHO’s second DirectorGeneral at the age of 42. Candau was strongly supported in his election by Fred Soper who believed that disease campaigns were a necessary prelude to the building of a general health service. Together, they convinced the WHA to create the Malaria Eradication Programme (MEP) in 1955, focused on the use of DDT to eradicate the vector. Despite Candau’s strong support for malaria eradication, he was notably unenthusiastic in his support for a similar campaign against smallpox, because of his experience, during his training in Brazil, of the ill-fated yellow fever program. He doubted the feasibility of vaccinating the world’s population, given the inaccessibility of remote populations. When long-standing support by the Soviet Union for the Smallpox Eradication Programme was combined with growing US support for such an effort, Candau strongly resented the lack of resources offered to the WHO for such a

Structure and functions

29

purpose. Believing such funds would not be forthcoming, he declared that it would be impossible to undertake the campaign unless an additional US$2.4 million was provided to the WHO. To his surprise, industrialized countries committed the necessary resources and, in a rare vote in the WHA, member states agreed to create and fund the Intensiﬁed Smallpox Eradication Programme. The program was declared to have achieved its historic goal in 1980, while malaria eradication was downgraded to the Malaria Control Programme in 1971. Despite his misplaced support for malaria eradication, Candau was re-elected to successive terms in ofﬁce in 1958, 1963 and 1968. Time magazine described him as no bedside physician but a doctor’s doctor because of his organizational and managerial skills. Being from a nonaligned country, he also had a political advantage over Canadian Brock Chisholm during the height of the Cold War. After he was elected, the Soviet Union and Eastern bloc countries, which left the WHO in 1949, accepted his neutrality and returned en masse. Described as smooth in manner and speech as in his grooming, Candau sought to avoid such politics, focusing instead on practical matters such as operational tasks and raising ﬁnances for the organization. Sources: “Doctor to the World,” Time, 1 June 1962; Elizabeth A. Casman and Hadi Dowlatabadi, The Contextual Determinants of Malaria (Washington, DC: Resources for the Future, 2002); Cynthia Needham and Richard Canning, Global Disease Eradication: The Race for the Last Child (Washington, DC: American Society for Microbiology Press, 2003); and Jonathan B. Tucker, Scourge: The Once and Future Threat of Smallpox (New York: Atlantic Monthly Press, 2001).

In following a member states-led process of priorities, the WHO saw a continued proliferation of programs without a corresponding increase in resources. The result was a spreading of limited resources across a broader range of activities, at times with only one or two staﬀ covering speciﬁc health topics. As described in Chapter 5, the creation of new global health initiatives to tackle speciﬁc health needs pointed to the need for the WHO to deﬁne its relative role more clearly. Under Gro Harlem Brundtland (1998–2003), the WHO’s current structure at headquarters was created through a judicious degree of pruning and rationalizing “to make WHO more responsive, more focused and more visible.”2 She stated that “WHO is being asked to do

30

Structure and functions

more and more against this background of profound social, political and economic transformation. … Given the magnitude of the global health agenda, it is evident that WHO cannot do everything.”3 Brundtland pared down the organization’s 50 programs at headquarters to 35, grouping them into nine “clusters” to create “a ﬂatter structure, better communication, more transparency.”4 An Executive Director was appointed to head each cluster5 to create “new opportunities to see WHO’s activities more in connection, to secure more unity of purpose.”6 As well as its own programs, the WHO hosts a number of shared initiatives. One of the most established and respected is the UNICEF/ UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), established in 1975. The mission of TDR is to help coordinate, support and inﬂuence global eﬀorts to combat a portfolio of major diseases which disproportionately aﬀect poor and marginalized populations. With funding from the four cosponsoring organizations, 22 countries and 12 other organizations such as foundations, TDR selects, guides, funds and develops research carried out by others, acting as a “global facilitator” of research and training. Similarly, the WHO headquarters hosts the Stop TB Partnership Secretariat, a network of more than 500 international organizations, countries, donors from the public and private sectors, and nongovernmental and governmental organizations formed in 2000 and working to eliminate tuberculosis as a public health problem.

Regional oﬃces: achieving strategic focus within a decentralized structure The creation of the WHO in 1948 required the incorporation of existing regional health organizations, and the creation of new regional bodies to ensure a geographical balance (Table 2.1). By 1951 all six regional oﬃces of the WHO were established to support the organization’s work in Africa (AFRO), the Americas (AMRO), the Eastern Mediterranean (EMRO), Europe (EURO), the Western Paciﬁc (WPRO) and Southeast Asia (SEARO). Each member state is allocated to a regional oﬃce, primarily for geographical reasons, although there remain some geographical anomalies. For example, Israel is a member of the EURO because of objections by Arab countries of the EMRO to cooperate with it. Member states are represented on a corresponding Regional Committee,7 a plenary body largely comprised of ministers of health. The secretariat of each regional oﬃce roughly corresponds in structure to Headquarters, with the addition of programs speciﬁc to

Structure and functions

31

Figure 2.1 The cluster structure of the World Health Organization. Source: Reprinted from Gavin Yamey, “WHO in 2002: Have the Latest Reforms Reversed WHO’s Decline?” BMJ 325(7372): 1107–12 (9 November 2002), www. bmj.com/cgi/reprint/325/7372

the region. Each oﬃce is headed by a Regional Director, who serves as the chief technical and administrative oﬃcer for the WHO in that region. Regional directors are formally appointed by the Executive Board upon nomination by the respective Regional Committee. The six regional oﬃces of the WHO are somewhat unique within the UN system in their degree of independence and decision-making power. Regional committees meet annually to formulate policies with a

32

Structure and functions

Table 2.1 Regional ofﬁces of the World Health Organization Region

Regional Ofﬁce Secretariat

Current Regional Director

Africa (AFRO) Europe (EURO) Southeast Asia (SEARO) Americas (AMRO or PAHO) Eastern Mediterranean (EMRO) Western Paciﬁc (WPRO)

Brazzaville Copenhagen New Delhi Washington DC Cairo Manila

Luis Gomes Sambo Marc Danzon Samlee Plianbangchang Mirta Roses Periago Hussein A. Gezairy Shigeru Omi

regional dimension, review the regional program budget proposed by the Regional Director, and monitor the WHO’s collaborative activities for health development in that region. In principle, decisions are then formally approved by the WHA and the Executive Board to ensure that they are appropriate to global policies. In practice, the agendas of these bodies have grown to such an extent that tight policy and budgetary control is not possible. This has given Regional Directors and committees considerable discretion over their activities. There were two main reasons for the creation of regional oﬃces. The ﬁrst was early recognition that eﬀective international health cooperation required eﬀective institutional links to all member states. An organizational structure encompassing headquarters, regional and country level activities was expected to enhance the WHO’s capacity to carry out its responsibilities worldwide. Achieving an appropriate balance of authority and resources across these three organizational levels, however, has remained an ongoing subject of debate. Some argue that “regionalization, so liberally interpreted, has been one of the factors which has contributed most to success—particularly in securing worldwide co-operation.”8 Others, however, have supported a more centralized WHO, based on concerns that an overly regional independence tipped the balance away from Headquarters, undermining the WHO’s capacity to assert overall leadership. Indeed, the WHO’s regional structure received early criticism by the Technical Advisory Board (TAB) of the UN Special Fund, the mechanism through which, until 1950, UN specialized agencies coordinated their plans and work. The TAB argued that the WHO’s work plan and regional structure impeded eﬀorts to achieve an integrated development assistance program, a criticism that continues to be raised to the present day. The second, and more politically based, reason for a decentralized structure was the prior existence of established regional health organizations at the time of the WHO’s creation. While it was widely agreed

Structure and functions

33

that these organizations needed to be integrated into the WHO’s structure, negotiations over the distribution of authority, membership and ﬁnancing proved highly sensitive. Supporters of the PASB, later the PAHO, were ﬁercely protective of that organization’s successful record in disease control (e.g. yellow fever). Indeed, tensions emerged during the International Health Conference over the desire by the US and other governments of the region to maintain the PAHO’s autonomy.9 The independence of regional oﬃces has been the subject of ongoing debate, focused on their highly politicized nature (especially their appointment of country-level staﬀ) and variable capacity to eﬀectively deliver WHO programs. As Fiona Godlee writes, Regional directors are elected by their constituent countries rather than appointed by the director general, and they can hire and ﬁre staﬀ within their regions. Especially important is their responsibility for appointing country representatives—the WHO’s front liners, who, because of lack of training and resources, form one of the weakest links in the WHO’s chain of inﬂuence.10 When Brundtland took oﬃce as Director-General in 1998, she recognized that dealing with regional oﬃces would be one of her most difﬁcult tasks. Her determination to reform the relationship between Headquarters and regions was expressed in her leitmotif “One WHO: WHO is one. Not two—meaning one ﬁnanced by the regular budget and one ﬁnanced by extra-budgetary funds. Not seven—meaning Geneva and the six regional oﬃces.”11 Despite her eﬀorts to unify the organization, as Gavin Yamey writes, “My impression from interviewing WHO staﬀ and health professionals outside the organization is that the independent functioning of the regions is still getting in the way of WHO’s eﬀectiveness.”12 Similarly, an external review of the Roll Back Malaria initiative noted: “The eﬀectiveness of [African Regional Oﬃce] professionals is constrained, however, by the system in which they work and by deﬁciencies in their relationships with WHO headquarters.”13 Thus, in practice little has been achieved to rein in the autonomy of regional oﬃces. An open letter to Margaret Chan in 2006 echoed familiar concerns, calling for the new Director-General to look for ways to bring regional oﬃces and headquarters closer together, so that all parts of the organization share a core mission and communicate common information, with a particular focus on getting information from the ﬁeld to Geneva. To get there, a reread of the WHO constitution might be in order—there is room

34

Structure and functions within it for regions to be more directly linked to the main part of the WHO than they currently are.14

WHO country oﬃces and representatives In 2005 there were around 144 WHO country oﬃces (COs) located in member states deemed in need of country-level support.15 While of varying size, each CO is headed by a WHO Representative (WR) who is a trained physician and not a national of that country. The WR is appointed by and answerable to the relevant regional oﬃce, and is supported by health and other experts, both foreign and local, and the necessary support staﬀ. While there is considerable variation in the size and scope of activities of COs, the overall role of the CO is to work with the government to implement WHO policies and programs and, more generally, support the development of the country’s health system. COs, generally located within a country’s ministry of health, have three main functions: policy advice and technical support; information, public relations and advocacy; and management and administration. Additional demands have come from the growing number of other institutional actors in the health sector, and from the need for the WHO to respond to emergencies and natural disasters.16 International liaison oﬃces serve a similar purpose to that of COs but on a smaller scale. These oﬃces are often found in countries that want a WHO presence but do not have the substantial health needs that require the presence of a CO. Liaison oﬃces are headed by a liaison oﬃcer, who is a national of that particular country. COs remained in low-key operation for much of the WHO’s history, when eﬀective, serving as a conduit of WHO expertise to member states. By the 1990s, amid perceptions of the declining prominence of the WHO in health development, questions were raised about the appropriateness and adequacy of the WHO’s presence at the country level. One particular criticism of COs was the process of appointing WRs, seen as a way for regional directors to distribute political favors rather than a means of strengthening the capacity of ministries of health. In 1997, six governments (known as the Oslo Group) sponsored an independent study of WHO country oﬃces.17 The study analyzed WHO activities in 12 countries to review the WHO’s achievements in relation to needs and capacities; identify the potential for more eﬀective support to programs; and contribute to the improvement of the WHO’s overall performance. One of the key recommendations of the study was the concept of “essential presence” as the basis for the WHO’s relationship with its member states. The study found that the WHO’s

Structure and functions

35

presence did not always match a country’s speciﬁc needs and capacities, and that there needed to be a continuum between a major presence in poor countries (where needs are great) and collaborative links (rather than a physical presence) with high-capacity countries. The study recommended that the WHO rationalize the number of COs, given limited resources and varying need; strategically adapt the size and role of COs to the needs and contexts of speciﬁc countries into an “essential presence”; strengthen the capacity of COs through the depoliticization of WR appointments and delegation of authority to the country level; and broaden the working relationships of COs beyond ministries of health. In response to these recommendations, a report was presented by the Director-General to the EB in January 1998 proposing that: appropriate mechanisms for WHO representation and coordination at country level according to the economic development and health status of the Member States, and considered also how the functions could be improved while concentrating more of WHO’s scarce resources in countries in greatest need.18 As part of these discussions, the relative balance of resources across the six regions became a point of contention. The formula for allocating resources to countries and regions had been historically based on previous practice, with each region’s share remaining roughly unchanged since 1948. Individual regional oﬃces additionally receive extrabudgetary funds (EBFs) provided voluntarily by member states. The changing fortunes of individual regions after the Cold War, notably economic growth in SEARO and WPRO countries and decline of EURO (mainly Eastern European) countries, led to calls for a reallocation of resources. Following a review of existing arrangements,19 it was agreed that a new system be implemented from 2000–2001. Various models of country-level presence were described, notably one based on the UNDP’s human development index, possibly adjusted for such health indicators as immunization coverage.20 This was followed by the creation of a Working Group on Partnership in countries and the ﬁrst global meeting of WRs. One outcome of these various groups and meetings was the introduction of Country Cooperation Strategies (CCS), described as “the practical, country-based expression of the corporate strategy for the WHO Secretariat. … [and] a framework which encompasses the entirety of WHO support, ensuring that the diﬀerent levels of the Organization complement one another.”21 Each country strategy combines

36

Structure and functions realistic assessment of country needs, with WHO country and regional priorities, taking into account the corporate strategy reﬂected in the current WHO General Programme of Work. The result is an agreed statement of how national authorities and WHO will prioritize the use of WHO resources within the country, whether these resources come from the country program, the regional oﬃce, headquarters or other sources, such as WHO collaborating centers.22

In 2002 the expanded use of CCSs was announced as part of the WHO’s Country Focus Initiative (CFI). By the end of 2006, there were 131 CCSs and a “second generation” had started in at least two regions. The latter improves the quality of CCS processes and documents with “better analysis of challenges and opportunities at country level, improved selectivity for the strategic agenda with more focus on health systems, and attention to human rights, gender and social determinants of health.”23 There remains ongoing debate about how the WHO should distribute its resources and eﬀorts across its three institutional levels. Facing ﬁerce competition from new global health initiatives, as discussed in Chapter 5, the organization has been under growing pressure to demonstrate its relevance in the form of concrete achievements on the ground. The WHO has responded by seeking to concentrate country-level activities more strategically, in countries in greatest need, and to tailor its presence to the varying needs of speciﬁc member states. This has been balanced, however, by a reluctance to devolve an even greater degree of authority away from headquarters, undermining the ability of the WHO to act coherently as a single organization.

WHO collaborating centers While the Secretariat is staﬀed by some 8,000 health and other experts, and support staﬀ on ﬁxed-term appointments, working at headquarters, the regional oﬃces, and in countries, the WHO draws on additional expert advice from a large array of institutions who act as designated collaborating centers. The idea of using national institutions for international purposes dates back to the League of Nations, when national laboratories were ﬁrst designated as reference centers for the standardization of biological products. The WHO appointed more reference centers upon its conception, starting in 1947 with the World Inﬂuenza Center in London, which provides worldwide epidemiological surveillance. In 1949, the WHA agreed that the organization should not consider “the

Structure and functions

37

establishment, under its own auspices, of international research institutions,” but rather that research is “best advanced by assisting, coordinating and making use of the activities of existing institutions.” An institution may be designated a collaborating center when there has been successful collaboration in implementing jointly planned activities in support of WHO programs and, at the same time, there is a concrete perspective of the continuation of such collaboration. Both institutions that show the capacity to fulﬁll a function or functions relevant to the Organization’s program and objectives, and institutions of high scientiﬁc and technical standing that have already attained international recognition, may qualify for designation as WHO collaborating centers. Designation is made with the agreement of the head of the establishment to which the institution is attached, or with that of the director of the institution, if it is independent, and after consultation with the national government. An institution is designated initially for a term of four years; the designation may be renewed for the same or a shorter period. Collaborating centers provide overall scientiﬁc and technical guidance, as well as direct support of global, interregional and regional technical cooperation programs for national health development. Centers must also participate in the strengthening of country resources, in terms of information, services, research and training, in support of national health development. The functions of collaborating centers may include the following: collection, collation and dissemination of information; standardization of terminology and nomenclature, of technology, of diagnostic, therapeutic and prophylactic substances, and of methods and procedures; development and application of appropriate technology; provision of reference substances and other services; participation in collaborative research developed under the Organization’s leadership, including the planning, conduct, monitoring and evaluation of research, as well as promotion of the application of the results of research; training, including research training; and the coordination of activities carried out by several institutions on a given subject. In fulﬁlling these functions, collaborating centers are an essential and cost-eﬀective cooperation mechanism, which enables the WHO to fulﬁll its mandated activities and to harness resources far exceeding its

38

Structure and functions

own. The WHO gains access to top centers worldwide and the institutional capacity to ensure the scientiﬁc validity of its work. Conversely, designation as a WHO collaborating center provides institutions with enhanced visibility and recognition by national authorities, calling public attention to the health issues on which they work. It opens up improved opportunities for them to exchange information and develop technical cooperation with other institutions, in particular at international level, and to mobilize additional and sometimes important resources from funding partners.

Financing and budgeting The WHO is ﬁnanced in part by the assessed contributions of its member states, known as regular budget funds (RBFs), calculated biennially according to the UN scale of ability to pay (gross national product and population). According to this system, a small number of high-income countries provide most of the organization’s core funding. In 1962, more than half of RBFs were provided by the Soviet Union, United Kingdom and United States, and a further quarter by Canada, China, France, Germany, India, Italy and Japan. To ensure that the WHO would not become overly dependent on a single member state, it was agreed that no country would pay more than one-third of total RBFs. The largest single contributor has remained the United States at 25 percent. In addition to RBFs, the Constitution states that the WHO “may accept and administer gifts and bequests made to the Organization provided that the conditions attached to such gifts or bequests are acceptable and are consistent with the objectives and policies of the Organization.”24 These additional contributions, known as EBFs, are given voluntarily by other UN organizations, member states, NGOs, private companies or individuals. Until the mid-1950s, EBFs came primarily from two sources. The ﬁrst was the Expanded Programme for Technical Assistance (EPTA), created in 1949 to promote economic development through the transfer of technical skills of the UN and its specialized agencies. Working through a technical assistance board on which the WHO Director-General served, EPTA channeled EBFs through UN organizations for development activities. These funds were used by the WHO to strengthen health administrations, control communicable diseases, and train professional and auxiliary staﬀ. The second source of EBFs was the UN Special Fund, established in the 1950s to mobilize greater resources for UN economic and social development activities. The fund was consolidated in 1962 as the UNDP.

Structure and functions

39

The launch of the Intensiﬁed Malaria Eradication Programme in 1955 and the Intensiﬁed Smallpox Eradication Programme in 1967 (see Chapter 3) led to a substantial rise in EBFs to the WHO. In 1956, US President Dwight Eisenhower decided to provide substantial funds for malaria eradication on both humanitarian and foreign policy grounds. Other major contributions came from UNICEF. A similar pattern was followed by the Smallpox Eradication Programme which, after an initially slow start, received most of its funding from EBFs. While EBFs came to provide a vital source of ﬁnancing for disease control and eradication programs from the 1950s, the most signiﬁcant growth of EBFs occurred from the 1970s onwards. The creation of special programs for research on such areas as human reproduction and tropical diseases brought an inﬂux of new ﬁnancing. This rapid expansion of EBFs prompted the EB to initiate a major study in 1975 of the “increasingly important role which extrabudgetary resources have played and will continue to play in supplementing the regular program budget of WHO.”25 The study found EBFs to be a welcome source of funding, especially given the expansion of technical cooperation activities being undertaken by the WHO. Within this context, it concluded that “if WHO is to pursue its constitutional mission it is evident that the upward trend in extrabudgetary resources must continue.” This positive view of EBFs set the scene for even more rapid increases during the 1980s and 1990s. In 1970, EBFs accounted for 20 percent of total WHO expenditure, with over half of these funds coming from other UN organizations. By the early 1980s, the rise in EBFs represented not only a “vote of conﬁdence” in special WHO programs, but also a “vote of non-conﬁdence” for some activities funded by its regular budget, namely campaigns on essential drugs, breast milk substitutes and health for all. In a context of ﬁnancial austerity, major donors (known as the Geneva Group) introduced a policy of zero real growth (adjusting for inﬂation) in the 1980s to the RBFs of all UN organizations. In part, this policy was in response to the alleged “politicization” of certain UN organizations, notably UNESCO and the International Labour Organization (ILO). This policy remained in place until 1993, when an even more austere policy of zero nominal growth (not inﬂation adjusted) was introduced, reducing the WHO’s budget in real terms. While RBFs have been frozen and then shrunk, EBFs continued to increase in absolute terms and as a proportion of the total budget. By the 1990–91 biennium, EBFs exceeded RBFs for the ﬁrst time (Table 2.2).26 By the mid-1990s, the change in the balance between RBFs and EBFs raised concerns about the functioning of the WHO, and led three “like minded” governments (Australia, Norway and the United

40

Structure and functions

Table 2.2 Proportion of WHO budget from RBFs and EBFs by biennia Biennium

Regular Budget Funds ($ millions)

% RBFs

Extrabudgetary Funds ($ millions)

% EBFs

Total Budget ($ millions)

1970–1971 1972–1973 1974–1975 1976–1977 1978–1979 1980–1981 1982–1983 1984–1985 1986–1987 1988–1989 1990–1991 1992–1993 1994–1995 1996–1997 1998–1999 2000–2001 2002–2003 2004–2005 2006–2007

142.4 180.7 227.7 285.7 352.4 427.3 468.9 520.1 543.3 609.0 653.7 734.9 822.1 822.1 849.6 842.7 842.7 880.1 915.3

62 59 54 52 50 47 49 52 51 43 41 42 41 44 47 43 38 31 28

42.3 65.1 122.9 169.1 245.8 472.5 487.2 470.0 520.4 803.8 954.8 999.4 1200.5 1040.5 930.0 1097.0d 1380.5d 1944.0d 2398.1d

18 21 29 31 35 53 51 48 49 57 59 58 59 56 53 57 62 69 72

230.3a 306.4a 422.5a 548.7a 708.6a 899.8b 956.1b 990.1b 1063.7b 1412.8b 1608.5b 1734.3b 2022.6b 1862.6b 1770.0c 1939.7e 2222.7e 2824.1f 3313.4f

Notes: a Total expenditure excluding the International Agency for Research on Cancer and Pan American Health Organization as cited in Table A4.1 of Vaughan et al. 1995. b Proposed budget including PAHO and IARC as cited in Table A4.4 of Vaughan et al. (1995). c WHO. Proposed Budget 2004–2005 Performance Assessment Summary. Geneva, May 2006. http://whqlibdoc.who.int/hq/2006/WHO_PRP_06.1_eng.pdf d Figure refers to “Other Sources” in WHO budget and ﬁnancial documents at headquarters only, and exclude contributions provided voluntarily at regional and country levels.e Expenditure plan as cited in WHO. Proposed Programme Budget for 2002–2003. 54th World Health Assembly, Doc. A54/INF.DOC./8, 1 May 2001. http://ftp.who.int/gb/archive/pdf_ﬁles/WHA54/ea54id8.pdf f WHO. Notes on Revisions to the Proposed Programme Budget 2006–2007 since the 115th Session of the Executive Board. Geneva: 2005. http://www. who.int/gb/ebwha/pdf_ﬁles/PB2006/P1-en.pdf

Kingdom) to commission a major study of WHO funding (see Chapter 5). The main conclusions of the study (known as Oslo I) were: WHO programs have variable capacity to attract EBFs (e.g. infectious diseases versus health systems development) which can distort and inﬂuence the balance between and within established programs;

Structure and functions

41

there is ﬁerce competition for EBFs, given resource constraints, which serves to undermine cohesion across programs and levels of the organization; there is variation in systems of accountability and transparency in the use of EBFs; and the time-limited nature of EBFs prevents longer-term program planning.27 In response to these concerns, the WHO set up a working group in 1997 to develop a strategic approach “to improve mobilization, allocation and utilization of resources.”28 The approach emphasized the need for “one single and coherent WHO under the guidance of its governing bodies,” as well as the need to be “responsive to the policies, agendas and preferences of various donors.” As well as the introduction of new systems for resource management of EBFs, in line with RBFs, the WHO called on donors to undertake a “minimum level of earmarking … to facilitate a more eﬀective use of resources.” The organization’s budgeting process has been closely linked to its funding sources. Since 1980–81, the WHO’s work program has been funded on a biennial (two-year) budgeting cycle carried out by the Division of Budget and Finance under the responsibility of the Director-General (DG). Prior to this, budgets were approved on an annual basis. The biennial program and budget were introduced to reduce the time spent by the governing bodies and Secretariat on such matters. The change was also intended to promote longer-term planning, facilitate implementation of program budgeting, allow greater ﬂexibility in the management of funds, and facilitate interagency comparability of programs and ﬁnancial data. However, as discussed in Chapter 5, concerns have persisted about the capacity of the organization to undertake strategic planning, given the balance between RBFs and EBFs, and the broad nature of the WHO’s mandate. By 2006, RBFs ($915 million) had shrunk in real terms and relative to EBFs ($2,398 million). The WHO exerts discretionary control over the former, as assessed contributions from all member states. EBFs, in contrast, are largely earmarked by funders (mainly bilateral aid agencies) for speciﬁed purposes and time periods, a practice that has increased as donors have sought more control over planning and management. In principle, the WHO’s General Programme of Work sets out the organization’s priorities. In practice, funders can heavily inﬂuence what is given greatest attention, leaving RBFs to gapﬁll across various programs and geographical regions. Even allocating RBFs internally requires the organization to engage in tricky negotiation.

42

Structure and functions

Eﬀorts to reallocate RBFs across programs and regions, and align them more closely with agreed priorities, have often met with intransigence, calling for political skills of the highest order to overcome them. The late payment of RBFs by some member states has also posed diﬃculties for the WHO’s budgeting process. In 1992 only 49 percent of member states paid their RBF contributions on time and in full (Table 2.3), rising to 61 percent by 2001. As reported by the DirectorGeneral, “[l]ate payment has been of serious concern” as delivery of the organization’s program budget on time requires receiving such contributions.29 For some countries, such as Somalia and the Dominican Republic, arrears have been due to ﬁnancial hardship and the WHO has sought to reschedule payments. Nonetheless, the WHO has taken a harder stance on such countries in recent years, invoking its powers to suspend the voting rights of member states in arrears. By 2005, the voting rights of 20 countries30 had been suspended.31 While cumulatively, the arrears of the above countries have posed a growing problem for the WHO, given the size of its assessed contributions, the non-payment of RBFs by the United States has represented a major ﬁnancial diﬃculty. The United States has become the largest debtor to the UN as a whole, reaching $2 billion by 2001. Arrears to

Table 2.3 Payment status of member states and associate members in respect of current-year contributions to the effective working budget

30-Nov-92 30-Nov-93 30-Nov-94 30-Nov-95 30-Nov-96 30-Nov-97 30-Nov-98 30-Nov-99 30-Nov-00 30-Nov-01

Number of members which had paid contributions in full

Number of members which had paid contributions in part

Number of members which had made no payment

81 90 95 95 98 99 100 109 114 118

32 (19 %) 23 (12 %) 17 (9 %) 14 (7 %) 29 (15 %) 27 (14 %) 25 (13 %) 27 (14 %) 28 (15 %) 26 (13 %)

53 73 75 78 65 66 68 57 51 49

(49 %) (48 %) (51 %) (51 %) (51 %) (52 %) (52 %) (56 %) (59 %) (61 %)

(32 %) (39 %) (40 %) (42 %) (34 %) (34 %) (35 %) (30 %) (26 %) (25 %)

Total number of members and associate members 166 186 187 187 192 192 193 193 193 193

Source: Based on WHO Executive Board, Status of collection of assessed contributions including Members in arrears to an extent which would justify invoking Article 7 of the Constitution, Report by the Director-General. 109th Session, Provisional Agenda Item 5.1, Doc. EB109/20, 20 December 2001.

Structure and functions

43

the WHO rose from around $20 million in 1996 to $35 million in 1999. In May 2001, the US government won a reduction in its budgetary contributions to the World Health Organization from 25 percent to 22 percent (around $25 million), amid protest by other member states, notably Cuba, China and Pakistan, that “developing countries were supposed to pick up the tab.”32 Despite facing a budget deﬁcit of $21 million for 2002, Director-General Brundtland assured member states that the deﬁcit from reduced US contributions would be found from miscellaneous funding accounts. She warned, however, that it would be “hard for us, and will limit our ability to address some of the newer imperatives that demand our attention.”33 The need for more predictable and stable funding for the WHO led the draft medium-term strategic plan of 2008–13 to call for an increase in RBFs to $1,000 million in order to maintain a “reasonable balance” between RBFs and EBFs. In addition, prominent ﬁgures in public health called on major donor governments to increase funding to the WHO: In terms of real purchasing power, WHO’s regular budget ($843 million for the current biennium) has declined by an estimated 20 percent during the past decade, jeopardizing its ability to carry out its mission and programs. In 1998, the United States gave WHO $46.1 million in extrabudgetary contributions. Although it is the largest contributor to speciﬁc programs, it ranks on both a perperson basis and as a share of gross domestic product far below Norway, Denmark, Sweden, the Netherlands, the United Kingdom, Australia, and Canada. We believe that the United States should reverse this situation. If matched by other donors, a 3.7 percent increase in our assessed contribution, which would amount to less than $4 million annually, would allow WHO to cover the price increases and exchange rate ﬂuctuations it can reasonably be expected to face. On economic, political, and humanitarian grounds, the US support for WHO must not be allowed to erode. Given the WHO’s record of success and its new vision, it is incumbent upon us to pay our arrears and enlarge our ﬁnancial contribution so that the WHO can fulﬁll its global mandate.34 Some donor governments acknowledged these problems, along with the WHO’s eﬀorts to reform its ﬁnancial management, budgeting and management practices. Memorandums of understanding were agreed for more predictable “core” EBFs, along with increasing RBFs.35 Ongoing reforms within the WHO under Brundtland and Lee resulted,

44

Structure and functions

inter alia, in reduced administrative costs and the introduction of a results-based management approach: Developing guiding principles for strategic resource allocation is an opportunity to further strengthen the Organization’s resultsbased management approach. The correct balance must be struck between a results-based budgeting approach and the development of strategic resource allocation principles and criteria. While the two approaches are not necessarily mutually exclusive and may even be complementary, care must be taken not to revert to a resourcebased approach, whereby resources are allocated in isolation from the strategic direction and objectives of the Organization.36 Despite such changes, successive Bush Administrations have continued to insist that existing and any increased ﬁnancial contributions to UN organizations be directly linked to further reform and performance. In summary, in relative terms the WHO’s budget of around $3,313 million (2006–7) is relatively modest compared with the ﬁnancing of national health systems. With such funds, the organization must support international health cooperation across 193 member states and a broad-ranging mandate. The capacity for the WHO to allocate resources more strategically, in response to pressure by donor governments to demonstrate “value for money” remains constrained by the ongoing shift to EBFs, much of which are earmarked by donors for speciﬁc purposes. For 2006–7, EBFs represent 72 percent ($2,398 million) of the WHO’s total budget. The reform of ﬁnancing and budgeting processes, begun in the late 1990s, continues within the organization but has yet to yield a major increase in resources.

Conclusion The WHO’s structure and functions are intended to reﬂect the organization’s universal membership and mandate to improve the world’s health. The plenary meetings of the WHA permit each member state to voice its views and pursue its health needs. The work of the EB, comprised of individuals acting in their technical capacity rather than as representatives of particular governments, is expected to be less subject to vested interests. In turn, the expert staﬀ of the Secretariat carries out the broad range of programs agreed by the two governing bodies. At the same time, its institutional features cannot be disentangled from the political history of international health cooperation. The establishment of its governing bodies and, in particular, the creation of regional

Structure and functions

45

and country oﬃces, has been a balancing act between institutional eﬀectiveness and political necessity. While the resultant structure has, in principle, distributed available resources worldwide, the appropriate balance of authority and responsibility between headquarters and regions has been an ongoing source of tension. Capacity across diﬀerent regions and countries also remains markedly unequal. The PAHO has been the strongest and most independent of the regional oﬃces, in part due to strong support from the US government. Other regional oﬃces are perceived as highly variable in their work, and it remains unclear whether they require more or less autonomy. At the country level, the WHO’s traditional role has been to support ministries of health through its country oﬃces. How large or small these oﬃces should be, and what level and type of resources are needed to support countries, also remains subject to ongoing debate. Since the 1940s, the WHO’s membership has steadily grown to embrace newly independent countries during the 1950s and 1960s, shifting power blocs during and after the Cold War, and the rise and fall of the economic and political power of certain countries and regions. Expectations of how the WHO should structure its programs and allocate its resources have changed accordingly. Thus, despite its being a specialized agency, and deemed to deal with largely scientiﬁc and technical matters, world politics set the wider context within which the WHO could pursue its mandate, by becoming embedded within its membership, funding and priority setting.

3

Global campaigns against disease

The founding of the WHO took place in the aftermath of the Second World War, during which disease rates soared among military and civilian populations. The destruction of basic infrastructure, such as housing, water and sanitation, widespread prevalence of poor nutrition, and the displacement of large numbers of people, allowed diseases such as tuberculosis, typhoid, poliomyelitis and diphtheria to reach epidemic proportions.1 Understandably, the new organization was looked to for immediate leadership to initiate and coordinate disease prevention, control and treatment programs. There was a strong feeling of humanitarianism after the horrors of the war were revealed.2 The post-war period also brought a sense of desire and optimism for improving world health. Medical knowledge and practice was advancing rapidly, including the mass production and use of penicillin, streptomycin (to treat tuberculosis) and other antibiotics. New vaccines oﬀered the potential to prevent and control diseases that caused substantial morbidity and mortality. The identiﬁcation of the structure of DNA (Deoxyribonucleic acid), the genetic blueprint to the development and functioning of all known living organisms, by Francis Crick and James Watson in 1953 opened up the study of diseases caused by defective genes. As science marched forward, so too did expectations of what a world health organization could and should achieve. Building on the work of existing regional and international health organizations (e.g. the PASB, International Red Cross, OIHP, LNHO and International Health Board of the Rockefeller Foundation), the WHO initiated a number of global campaigns against speciﬁc diseases in its ﬁrst two decades. In doing so, two conﬂicting approaches to “the attainment by all peoples of the highest possible level of health” were established which remain much debated to the present day. As C.L. Gonzalez describes, in his classic paper,

Global campaigns against disease

47

there are two apparently conﬂicting approaches … The ﬁrst, generally known as “the horizontal approach,” seeks to tackle the over-all health problems on a wide front and on a long-term basis through the creation of a system of permanent institutions commonly known as “general health services.” The second, or “vertical approach,” calls for solution of a given health problem by means of single-purpose machinery. For the latter type of program the term “mass campaign” has become widely accepted.3 This chapter examines the WHO’s pursuit of the “vertical approach” to health improvement, in the form of major campaigns against selected diseases. As Anne Mills describes, vertical programs are “directed, supervised and executed, either wholly or to a great extent, by a specialized service using dedicated health workers.”4 Over its 60-year history, the WHO has undertaken a wide range of disease campaigns (Table 3.1), and it is beyond the scope of this chapter to analyze these in detail. Instead, this chapter brieﬂy examines four initiatives—malaria, smallpox, HIV/AIDS and poliomyelitis. The longest running of these campaigns, against malaria, is a useful starting point for understanding the rationale for the vertical approach, its strengths and limitations. The second, smallpox, remains the most successful and celebrated eﬀort to date. The factors that contributed to the successful eradication of smallpox, and what this tells us about the role of the WHO, are described. The ﬁnal two examples, HIV/AIDS and poliomyelitis, illuminate the WHO’s more recent history. Together, the four initiatives represent two relative successes and two ongoing challenges.

The long battle against malaria The longest-running disease campaign by WHO has been against malaria, one of the most common infectious diseases, which today kills around one to three million people annually. Malaria is caused by protozoan parasites of the genus Plasmodium. The most serious forms of the disease are caused by Plasmodium falciparum and Plasmodium vivax, but other related species (Plasmodium ovale, Plasmodium malariae, and sometimes Plasmodium knowlesi) can also infect humans. Malaria parasites are transmitted by female Anopheles mosquitoes. The disease may have been a human pathogen for the entire history of the human species. References to the disease can be found throughout recorded history, from ancient China of 2700 BC to the European campaigns to colonize Africa during the nineteenth century. In May 1955 the WHA endorsed the Global Malaria Eradication Campaign with the aim of eliminating the disease from aﬀected areas.

1987–96 1988– present 1991– present 1997– present

Global Programme to Eradicate Dracunculiasis (guinea worm)

Global Programme on AIDS Global Polio Eradication Initiative Leprosy Elimination Strategy Use of temephos insecticide (Abate®) and improvement of water supplies

Oral poliovirus vaccine (OPV) Multi-drug therapy

Vector (blackﬂy) control and treatment with ivermectin (Mectizan®)

Heat-stable single-dose vaccine

1967–80 Intensiﬁed Smallpox Eradication Programme Expanded Programme of 1974– present Immunization (polio, diphtheria, whooping cough, tetanus, tuberculosis, and measles) 1974– Onchocerciasis (river blindness) present Control Programme

1955–70 Yaws

Vector control with DDT and larvicides, and treatment with chloroquine Injectable single-dose long-acting penicillin

1955–70 Global Malaria Eradication Programme

Interventions BCG vaccine

Disease programme

1947–51 International Tuberculosis Campaign

Date

Table 3.1 Selected mass campaigns against disease by WHO

New cases detected decreased by about 20 percent per year between 2002 and 2006 Global burden of cases reduced by 99 percent from over 3.5 million in 1980s to 10,674 in 2005 (9 endemic countries remain)

600,000 cases of blindness prevented, 18 million children born in now-controlled areas spared from the risk of river blindness and 25 million hectares of land safe for cultivation and resettlement Creation of UNAIDS Endemic countries decline from 125 to 4

Increase in children immunized against six target diseases from 5 percent to 80 percent in 1990; 2.1 million deaths in 2002 from vaccine-preventable diseases

Eradication nearly achieved, with sufferers reduced from 50 million to nearly zero; the WHO reported in 2007 that disease had increased again to half a million sufferers, mostly in poor, rural areas Eradication achieved in 1980

Mass vaccination led to decline in cases, but resurgence from 1980s leads the WHO to declare TB a “global emergency” in 1993 Eradication not achieved and replaced by control strategy

Outcome to date

Global campaigns against disease

49

The strategy focused on vector control using the inexpensive pesticide Dichloro-Diphenyl-Trichloroethane (DDT), sprayed inside homes to kill malaria-carrying mosquitoes, and treatment with anti-malarial drugs, notably chloroquine. While the resolution was adopted by a vote of 46 for, 2 against and 6 abstentions, and enjoyed high-level endorsement by Director-General Candau and the Director of the PASB (1947–59), Fred Soper, serious doubts were expressed within the public health community that the strategy would work. Soper, an American epidemiologist who had organized eﬀective campaigns against yellow fever, malaria and typhus fever before and during the Second World War, advocated spraying. Others were skeptical that infrastructure in the poorest countries would enable implementation.5 The program enjoyed some initial success. By 1967 malaria had been eradicated from all industrialized countries where it had been endemic, as well as some parts of Asia, Africa and the Americas. From the late 1950s, however, the feasibility of total eradication was already being questioned. Of particular concern were unforeseen problems with the use of DDT, notably its impact on local wildlife.6 Along with the dangers of over-reliance on DDT, the enormity of the challenge in subSaharan Africa, where the infrastructure was poor and transmission intense, began to be understood. Scientists had also underestimated the complexity of the disease and the potential for drug resistance. In 1969, the WHA re-examined the strategy and concluded that, while total eradication remained the long-term goal, it would not be feasible in Africa for some time. The strategy was shifted to the less ambitious goal of control through treatment with chloroquine.7 The ﬁnancial cost of the program made its lack of success even more disappointing. The cost of the program dwarfed other WHO activities over its 15-year existence, accounting for more than one-third of total expenditures and 500 staﬀ. The United States contributed nearly $1,000 million to the eﬀort, a key source of funding which ran out in 1963.8 There were enormous pressures to complete the eradication program before funding commitments dried up. Such fears proved accurate, as funding for malaria control declined signiﬁcantly in the 1970s, corresponding with an increase in drug prices and shipping costs. As Brian Greenwood describes, “Malaria control programs collapsed. Since they couldn’t eradicate malaria, they eradicated the malaria researchers.”9 The result was a resurgence of malaria from the early 1980s. Average annual cases were four times higher from 1982 to 1997 than during the period 1962–81. Africa was the worst aﬀected, with mortality increasing two- to threefold in some countries. The disease became the single

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Global campaigns against disease

biggest cause of death among young children, responsible for nearly 25 percent of deaths in children under ﬁve years.10 By the early 1990s, malaria had reached epidemic proportions, with 300–500 million clinical cases and 1.5 to 2.7 million deaths each year, and 90 percent of morbidity and mortality in sub-Saharan Africa.11 This alarming situation prompted a WHO-led Ministerial Conference on Malaria Control in Amsterdam in 1992. The conference adopted a World Declaration on the Control of Malaria and new Global Malaria Control Strategy, endorsed by the WHA, UN General Assembly and Organization of African Unity (OAU). In contrast to the eradication program of the 1950s and 1960s, the new strategy sought to be more ﬂexible (context speciﬁc), decentralized and disease (rather than parasite) focused. The role of WHO following the conference was to support countries in the development of national plans of action for malaria control.12 In 1998, further hope that greater impetus would be given to ﬁghting malaria when the disease was identiﬁed was, along with tobacco control, one of two key cabinet priorities of the newly elected Director-General. Urged by African leaders, Brundtland announced the creation of Roll Back Malaria (RBM), a partnership with the World Bank, UNDP and UNICEF. With the goal of halving the number of deaths from malaria by 2010, the partnership’s “roll back” title was carefully chosen to convey the strategy of pushing back, rather than eradicating, the disease. An important part of the RBM’s work was to raise the global proﬁle of malaria as a major development issue, and to galvanize political commitment: The Roll Back Malaria cabinet project was launched to call world attention to the problem of malaria; to let people know that there are some things we can do now which are tried and tested, and which work and that there could be better tools which could be developed and which would work even better such as vaccines or even genetically modiﬁed mosquitoes.13 Technical problems persisted in the implementation of the strategy, led by continued controversy over DDT, identiﬁed by environmentalists as among the “dirty dozen” persistent organic pollutants (POPs). By the 1980s, agricultural use of DDT had been banned in most industrialized countries, and was replaced in most anti-malarial uses by less persistent, and more expensive, alternative insecticides. Malariologists, however, blamed its restricted use on hundreds of thousands, and even millions, of unnecessary deaths from malaria. For example, Robert Gwadz of

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the US National Institutes of Health claimed the “ban on DDT may have killed 20 million children.”14 Similarly, Donald R. Roberts et al. found a causal link between the re-emergence of malaria in South America and decreased spraying of homes with DDT. They urged any debate on the costs and beneﬁts of DDT versus alternative insecticides to include the public health impact.15 Since 2001, 98 countries have signed the Stockholm Convention on Persistent Organic Pollutants (entered into force in 2004), which includes DDT on its restricted-use list, and longer-term plans for phasing it out. Importantly, the convention allows the use of DDT for malaria control. Correspondingly, in 2006 the WHO reversed its 30-year policy on using DDT. Anarﬁ Asamoa-Baah, WHO Assistant Director-General for HIV/AIDS, TB and Malaria, stated that “The scientiﬁc and programmatic evidence clearly supports this reassessment … DDT presents no health risk when used properly.”16 Another technical challenge for the WHO has been growing resistance to anti-malarial drugs, deﬁned as the ability of the parasite species to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within the limit of tolerance. Since the 1960s, sensitivity of the malaria parasite, Plasmodium falciparum, to chloroquine, the best and most widely used drug for treating malaria, has been in decline. Newer anti-malarial drugs have been discovered but these are either expensive or cause undesirable side eﬀects. Moreover, after variable lengths of time, the parasites become resistant to these drugs as well. Since the 1970s, for example, the border area between Cambodia and Thailand has been the epicenter of emerging multi-drug resistance, initially to chloroquine, followed by sulfadoxinepyrimethamine, meﬂoquine and, more recently, artemisinin-based combination therapies (ACT).17 However, it was ﬁnancial constraints which continued to be perhaps the most diﬃcult challenge. Despite high-level statements of support, funding for malaria control remained problematic. In 1991 malaria received $10 million from the US National Institutes of Health, compared to $1 billion allocated for HIV/AIDS.18 In 1996 it was reported that $84 million was being spent globally on malaria research,19 while morbidity and mortality from the disease caused an estimated annual economic loss of $12 billion to the African continent alone.20 Overall, according to the WHO Commission on Macroeconomics and Health (CMH) (see Chapter 5), around $2 billion was needed annually to halve the disease burden from malaria by 2010, compared with around $600 million being spent at that time. As David Alnwick (Project Manager, RBM) describes,

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Global campaigns against disease We hope that as we show success and results, more money will come in. I think we have to remain optimistic, but not naively optimistic. Malaria is certainly a tough challenge, we are not talking about eliminating or eradicating it. Our goal is to reduce the malaria burden particularly in Africa and to increase control in other parts of the world.21

The creation of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM) in 2002 was intended “to dramatically increase resources to ﬁght three of the world’s most devastating diseases, and to direct those resources to areas of greatest need.”22 The need for substantial scaling up of resources was given high-level support by the Group of Eight summits in 2000 and 2001, an African summit on infectious diseases in 2001, the UN General Assembly and SecretaryGeneral Koﬁ Annan. The ﬁndings of the CME, and the follow-up advocacy role of its chairman Jeﬀrey Sachs, played a critical role in convincing world leaders of the humanitarian and economic rationale for collectively tackling the three diseases. With pledges of around $2 billion, the Fund approved grants to 36 countries worth $600 million within its ﬁrst three months. On malaria, to date the GFATM has ﬁnanced 109 million bed nets to protect families from transmission of malaria, becoming the largest ﬁnancier of insecticide-treated bed nets in the world. It has also funded 264 million ACTs for resistant malaria. For the purposes of this book, what is notable is the decision to establish the GFATM as a separate entity from the WHO. As described in Chapter 5, the proliferation of global health initiatives during this period renewed concerns about overlapping mandates, poor coordination and wasted resources among various institutions. The Fund’s creators defended this decision on the grounds that it is a ﬁnancing mechanism (i.e. to attract, manage and disburse resources), rather than an implementing body. Thus, it relied on close working relationships with partner institutions involved in health and development issues “to ensure that newly funded programs are coordinated with existing ones.” Partners include the WHO, which provides technical assistance at the local, regional and global levels during the development of funding proposals and implementation of programs. The Fund is governed by an international Board comprised of representatives of donor and recipient governments, NGOs, the private sector (including businesses and foundations) and aﬀected communities. The WHO is one of several partners, including the World Bank, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and UNICEF, represented on the Board as ex oﬃcio members without voting rights. The location of

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the GFATM in Geneva also led the WHO initially to provide meeting and administrative facilities. The WHO’s role as a partner among many to the Fund, rather than its home, was also clearly inﬂuenced by a lack of donor conﬁdence that the former could be an eﬃcient means of rapidly disbursing large sums of funding. During the 1990s, the glacial pace at which the WHO’s bureaucracy operated ranked among the most frequently expressed criticisms of the organization. Supporters of the organization blamed weak internal capacity on the failure of donor governments to sustain regular budget funding, and punishing the organization by creating alternative institutional mechanisms served to further undermine it. Critics favored a more pluralist policy environment where competition among global health initiatives for available resources could encourage greater eﬃciencies within individual organizations. Correspondingly, the Fund grew to a staﬀ of 300 by 2007, a compromise between being an independent entity and avoiding becoming yet another UN-like bureaucracy. Upon taking oﬃce in April 2007, newly appointed Executive Director of the GFATM Michel Kazatchkine expressed his commitment to developing stronger ties with other organizations, as well as quadrupling donations to $8 billion annually by 2010.23 For the WHO’s Global Malaria Programme, its mandate has been malaria policy and strategy formulation, operations support and capacity development, and coordination of the WHO’s global eﬀorts to ﬁght malaria. It has focused on establishing and promoting policies, normative standards and guidelines for malaria prevention and control, including monitoring and evaluation, based on evidence and expert consensus. For example, global eﬀorts to tackle drug resistance have focused on: (a) the development of drugs which have diﬀerent or novel modes of action; and (b) examination of combinations of currently available drugs that have independent modes of action, in particular artemisinin-based combinations. The Programme points out that compliance and cost are important issues in achieving maximum coverage, itself an essential element in achieving the mass eﬀect required to achieve a reduction in resistance and transmission. Both approaches require collective action within and across countries to be successful, and it is where the WHO sees itself able to play a lead role in coordinating global eﬀorts. This technically based work, however, has not been without controversy. In 2004, a letter by Amir Attaran et al. to the Lancet accused the WHO and the GFATM of recommending cheaper, but ineﬀective, anti-malarials to African countries, given the problem of drug resistance:

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Global campaigns against disease For WHO and GFATM to provide chloroquine and sulfadoxinepyrimethamine treatments … at least wastes precious international aid money and at most, kills patients who have malaria. … When [African] countries seek ﬁnancial aid from [GFATM] to purchase ACT [artemisinin-based combination therapy], they are forcefully pressured out of it by governments such as the USA, whose aid oﬃcials say that ACT is too expensive … and WHO signs its approval.24

The WHO denied that its recommendations were a cost-saving policy, pointing to the organization’s support for ACT.25 This policy was reiterated in 2005 when the new head of the Global Malaria Programme, Arata Kochi, called on 40 pharmaceutical companies to stop selling artemisinin as a monotherapy.26 In support of the WHO’s policy, the Swiss-based company Novartis agreed to license and manufacture a new combination therapy, a mixture of an artemisinin derivative and another eﬀective anti-malarial drug, and to provide the drug at cost to the developing world. The role of WHO in facilitating this agreement is described by David Alnwick in this way: They knew they were not going to make a big proﬁt out of selling this drug in developing countries because it was so expensive. Therefore, they decided to oﬀer WHO the possibility of providing it at cost to developing countries where malaria is resistant. WHO agreed to carry out the international negotiation over the use of the drug. WHO liaises with ministries of health or other agencies at the national level and the pharmaceutical company to ensure that the drug will be used and distributed properly.27 For WHO, the ongoing half-century battle against malaria illustrates well the intertwined nature of the technical and political challenges facing global health cooperation. The disease has shown how diﬃcult it can be to sustain political momentum behind a disease predominantly aﬀecting the developing world, requiring substantial technical and ﬁnancial resources, and above all institutional leadership, to mobilize and implement eﬀective action across countries.

The eradication of smallpox: “Extraordinary achievements are possible”28 While malaria remains a major global health challenge in the early twenty-ﬁrst century, the eradication of another ancient disease, smallpox,

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has been the WHO’s greatest achievement to date. Smallpox has been described as the “most terrible of all the ministers of death,”29 a highly contagious disease caused by the variola major virus. The disease contributed to the decimation of indigenous populations of the Americas from the ﬁfteenth century, following arrival of Europeans to the continent. Over the twentieth century, it caused around 300 million deaths worldwide, largely in low- and middle-income countries.30 It threatened 60 percent of the world’s population—killing every fourth victim, scarring or blinding most survivors, and eluding any form of treatment. Despite the substantial disease burden caused by smallpox, the initial response by member states to the WHO’s proposal to establish a Smallpox Eradication Programme (SEP) was a resounding “no.” Smallpox was discussed at the WHAs of 1950, and between 1953 and 1955, with the concept of eradication rejected as unrealistic and too complex. It was not until 1958, following the successful national smallpox eradication program in the Union of Soviet Socialist Republics, that eradication was demonstrated to be feasible. Led by Deputy Minister of Health Viktor Zhdanov, whose report to the WHA described in detail the Soviet program based on compulsory vaccination, discussions at the WHA led to the broad endorsement of the proposed global eradication program.31 The timetable for achieving eradication, and the mobilization of the required resources to do so, remained problematic. The Soviet government, which rejoined the WHO in 1957 after withdrawing in 1948, donated 25 million doses of vaccine to the WHO, with additional oﬀers of assistance to Burma, Cambodia, Ghana, Guinea, India, Indonesia, Iraq and Pakistan. However, limited additional resources were forthcoming. While the Director-General estimated that $98 million was needed, smallpox received a total of $318,000 from 1959 to 1966. By comparison, the WHO’s “largest programme and its principal preoccupation,”32 the Malaria Eradication Programme, received $29.6 million during the same period. Given a staﬀ of ﬁve or six, the program seemed doomed to fail.33 One Soviet delegate to the WHA of 1965 expressed his irritation at the slow progress made, as follows: “Malaria eradication seemed to have been the favourite daughter of WHO, whereas smallpox eradication seemed to have been treated rather as a foster child.”34 It was not until the mid-1960s that an increase in support occurred. One reason was the development of the jet injector, a device capable of vaccinating up to 1,000 people per hour, and its adaptation for the smallpox vaccine. In 1965, staﬀ of the US Centers for Disease Control

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(CDC) worked with the PAHO to demonstrate in a pilot study in Brazil that the jet injector required far fewer human resources and cost only one-third of conventional techniques. A second factor was the decision by the US government to increase its technical and material support for smallpox and measles control programs in 20 western and central African countries. This commitment, according to Frank Fenner, was due to two factors: the need to demonstrate the US support for the International Cooperation Year to mark the UN’s twentieth anniversary; and a developing regional program for measles vaccination. As President Lyndon Johnson stated, “I intend to dedicate this year to ﬁnding new techniques for making man’s knowledge serve man’s welfare … I intend to expand eﬀorts to provide protection against disease.”35 A separate WHO program and budget for smallpox remained intensely debated. The United States argued that the WHO should limit itself to providing technical assistance and advice, and material support should be provided through other UN agencies, and bilateral and voluntary contributions to the WHO. The Director-General disagreed, recognizing that voluntary contributions would be insuﬃcient. For example, UNICEF, one of the largest potential contributors, stated that it “would be unable to participate.” Given increased requirements for malaria also, the organization might have proposed a substantial increase in RBFs, but this risked objections from industrialized countries. The following year, a proposed increase in the WHO’s overall budget of around 16 percent, and an allocation speciﬁcally for smallpox, were discussed in the EB and WHA. Developing countries expressed strong support for large increases in the budget and for disease eradication programs. The WHO pointed to the cost savings to countries from dealing with imported diseases. Nonetheless, most industrialized countries argued that the WHO’s budget should not increase at a rate faster than the growth in gross national product of its major contributors. Alternative proposals were put forth by the United States and France for smaller increases, both of which were defeated in favor of a $2.4 million budget for smallpox.36 The creation of the Intensiﬁed Smallpox Eradication Programme in 1967, therefore, did not stem from unconditional support from WHO member states. Nor did its subsequent path towards becoming the most successful disease program in the WHO’s history go smoothly with additional funding, staﬀ and resources. With national programs expected in 41 countries, resources remained thinly spread. As the WHO’s Chief Medical Oﬃcer for Smallpox Eradication, Donald Henderson, observed: “A deﬁciency of resources was a continuing

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problem and one that seriously jeopardized the international eﬀort.”37 Technical and logistical challenges remained, along with ethical issues surrounding compulsory vaccination. The experience of India illustrated the multiple hurdles faced. Financial and political instability accounted for some of the diﬃculties that beset the national program, but also signiﬁcant was disagreement over strategy that arose between WHO oﬃcials and India’s Director General of Health Services. The Indian government began to question some of the methods used by the WHO, amid reports of aggressive surveillance and coercive vaccination techniques.38 The last case of smallpox in India was detected in May 1975, followed two years later with the last naturally occurring case globally, in Somalia. Henderson summed up the enormity of this achievement: “For the ﬁrst time in history, mankind had vanquished a disease.”39 Yet the road to achieving this historic accomplishment was, perhaps in retrospect, somewhat bumpier than one would have expected. As Fenner writes, “Since smallpox was such a good candidate for global eradication, it is surprising that the commitment to undertake such a programme was so long delayed and, even after being accepted by the WHA, so ill-supported both within WHO and by most Member States.” Indeed, Donald Henderson admits that “eradication was achieved by only the narrowest of margins.”40 Within days of the announced success of the campaign, the Fogarty International Center convened a two-day meeting to explore the question of what diseases should be eradicated next. With the political and technical challenges of smallpox fresh in his mind, Henderson was among the most vocal in warning against further campaigns. A notable postscript to the smallpox story is the potential deliberate use of the disease as a weapon. Fears of such an eventuality rose sharply in the United States with the deliberate spread of anthrax following the events of 11 September 2001. Of particular concern is the possible dispersal of virus samples and expertise from the Soviet biological weapons program, after the collapse of the Soviet Union, to terrorist organizations and other unauthorized parties. Given the risk of such an eventuality, the US government has retained its own samples of smallpox on the grounds that there may be a need to produce a vaccine and even a pre-emptive vaccination campaign. In 1996 the WHA had recommended that all remaining stocks of smallpox virus be destroyed, a decision reaﬃrmed in 1999 with the proviso that stocks could be retained for research purposes. The WHO established an Advisory Committee on Variola Virus Research “to develop and oversee a research plan for priority public health.” As the editor of the New

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England Journal of Medicine wrote in 2002, “The decision on such a plan depends on the likelihood that terrorists will use smallpox as a weapon. A year ago it seemed unthinkable. Recent events, however, have raised the possibility that such an attack could conceivably occur.”41 Similarly, analysts at the right-wing think tank the Cato Institute concluded, “Judging from the September 11 attacks, the threat of direct terrorist attack against the United States is real. … A better approach than leaving the entire population at risk and responding only in the event of an actual smallpox attack would be to take preventive measures.”42 Within this heightened atmosphere, the US government created a Strategic National Stockpile of smallpox vaccine by 2004, from 15 million to 400 million doses, suﬃcient to vaccinate the entire US population in the event of an emergency. In addition, Secretary of Health Tommy Thompson announced in December 2004 that the government would make 20 million doses available to a global stockpile managed by the WHO as part of the Global Health Security Initiative: “The United States is proud to make a signiﬁcant contribution to a global stockpile that will serve as a critical line of defense in the event of a smallpox attack anywhere in the world. … This is an important step toward ensuring the health and safety of the American people.”43 As Jeﬀrey Drazen predicted, “Although medical facts frame the decision-making process, the choice in the end will be in the hands of our government oﬃcials.”44

The HIV/AIDS pandemic: an “even more urgent, diﬃcult and complex task”45 In 1981 the acquired immune deﬁciency syndrome (AIDS), and the human immunodeﬁciency virus (HIV) which transmits the disease, were announced in the US Centers for Disease Control’s Morbidity and Mortality Weekly Report as a new disease.46 Available evidence suggests the pandemic began in the 1970s.47 With little known about the extent of infection, modes of transmission or strategies for prevention and control, the disease silently spread to infect 100,000–300,000 people across at least ﬁve continents by 1980.48 The public health community began to investigate the new disease in the early 1980s. The ﬁrst International Conference on AIDS, held in 1985, marked oﬃcial acknowledgement of the severity of the disease’s rapid spread. Following a series of regional meetings, the WHO set up a small Control Programme on AIDS in 1986 within the Division of Communicable Diseases. Initially, Director-General Mahler considered

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HIV/AIDS to be a disease of developed countries. He was soon persuaded by Jonathan Mann, who founded Projet SIDA in Zaire and was appointed to lead WHO’s response, that it posed a major global health threat: “We stand nakedly in front of a pandemic as mortal as any pandemic there has ever been … In the same spirit that WHO addressed smallpox eradication, WHO will dedicate its energy, commitment and creativity to the even more urgent, diﬃcult and complex task of global AIDS prevention and control.”49 Funded by RBFs, the program was soon expanded to become the Special Programme on AIDS in 1987, and then the Global Programme on AIDS (GPA). The WHA recognized the disease as a “worldwide emergency” and approved a Global Strategy for the Prevention and Control of AIDS (Global AIDS Strategy), intended as a practical framework for developing common policies, guidelines and materials. In October 1987, Mann gave a special brieﬁng to the UN General Assembly, which led to the adoption of Resolution 42/8 conﬁrming the WHO’s “essential global directing and coordinating role” within the UN system on ﬁghting HIV/AIDS. National governments were encouraged to establish HIV/AIDS programs based on the strategy, and “appropriate organizations of the UN system” were requested to work closely with the WHO, including the channeling of technical and ﬁnancial support. A rapid expansion of WHO staﬀ, from funding EBFs and activities followed, making GPA the largest single program in the organization’s history. From 1987 to 1990, funding rose from around $18 million to $100 million, with staﬀ at headquarters increasing from 3 to over 100. By 1988 GPA had established projects in over 170 countries, with the development of national AIDS strategies the focus of these eﬀorts. Notably, early GPA activities sought a wide-ranging role in mobilizing and channeling resources, training health workers, advocating policy change, initiating and coordinating research, and raising public awareness. Of particular note were Mann’s eﬀorts to raise the priority given to the disease within the WHO, and to do so within a human rights framework.50 The 1988 WHA resolution on non-discrimination against People Living with AIDS51 reﬂected the core importance of human rights to Mann’s vision. Both aims brought him into direct conﬂict with Director-General Nakajima, who assumed oﬃce in 1988 after the surprise departure of Mahler. Nakajima immediately declared that the disease was being given too high a proﬁle: “Don’t talk to me about AIDS; I have malaria, which is a much bigger killer of people, on my hands.”52 He then set out to “normalize” the special program’s status, cutting resources and subjecting it to layers of unsympathetic

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management. This move reﬂected internal resentment at the rapid growth and special status accorded GPA by donors, as well as Mann’s unorthodox style. As Barton Gellman writes, “[a] master of back-room maneuvering, Nakajima began to clip the AIDS program’s wings.”53 The designation of the WHO as the lead UN agency on HIV/AIDS, and sensitivities surrounding the disease’s alleged associations with homosexuality, promiscuity and injecting drug users, slowed action by other UN organizations to develop their own activities. As the disease continued to spread, and the complexity of the challenge was realized, the need for expertise from other institutions became increasingly apparent. By the late 1980s, the World Bank, the UNDP, the UNFPA and UNICEF had established activities. Initially, these activities sought to complement the GPA. The World Bank began to ﬁnance HIV/AIDS prevention and control programs in 1986, primarily in Africa and Latin America, as part of broader health and social sector projects. Given its formal mandate “to promote economic development that beneﬁts poor people in developing countries,” the Bank recognized that HIV/AIDS was having an enormously adverse impact on economic development. An AIDS Strategy for Africa was put forth in 1988 and lending quickly grew in support of it.54 By 1995 cumulative lending for HIV/AIDS prevention reached $567 million, of which $256 million was for Africa alone.55 The socioeconomic impact of the disease in low-income countries led the UNDP to integrate HIV/AIDS into its work. With the WHO it formed the Alliance to Combat AIDS in 1988 in an eﬀort to bring together WHO expertise and UNDP resident representatives. The WHO’s biomedical approach to HIV/AIDS, with its emphasis on such interventions as blood safety, contrasted with the UNDP’s broader development approach. Despite the signing of an amended Memorandum of Understanding for the Implementation of the WHO/UNDP Alliance to Combat AIDS in 1992, clear tensions emerged between the two organizations. In 1992, the UNDP established its own HIV and Development Programme, headed by Elizabeth Reid. The program’s aim to address underlying socioeconomic factors contributing to the spread of the disease, and Reid’s strong emphasis on gender and equity, sparked direct conﬂict with the WHO. The impact of HIV/AIDS on women and children led UNICEF to initiate activities concerned with the growing numbers of AIDS orphans and HIV-positive children born to infected parents. In 1990 UNICEF formed a Working Group on AIDS focused on reducing transmission among young people, improving reproductive health among women and youth, and integrating prevention and care within

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existing programs. The UNFPA’s initial interest in HIV/AIDS stemmed from the disease’s demographic impact on populations, notably in lowincome countries. By the late 1980s, closer integration of sexually transmitted disease (STD) and HIV/AIDS control and prevention strategies was gaining support. For this purpose, the UNFPA and the GPA produced guidelines on the incorporation of AIDS-related work into maternal and child health (MCH) and family planning programs. The UNFPA assisted in the distribution of condoms, training of personnel and IEC (information, education and communication) activities. By the late 1980s, the WHO lead role in deﬁning a global HIV/ AIDS strategy was being undertaken within an increasingly crowded institutional arena. In 1988 the Interagency Advisory Group on AIDS (IAAG) was formed, with the GPA as chair and secretariat. Other mechanisms created during this time, to coordinate burgeoning UN involvement in HIV/AIDS, were Steering and Standing Committees on AIDS in the UN Department of International Economic and Social Aﬀairs. Despite these eﬀorts, coordination became a growing concern among major ﬁnancial donors. The WHO–UNDP Alliance had become a source of professional and personal conﬂict, rather than cooperation. The Standing Committee had become virtually inactive by 1992. An external review of the GPA carried out in 1992 concluded that collaboration among UN organizations needed “to be restructured if the experience and expertise of the specialised UN agencies are to be fully harnessed.”56 As knowledge and understanding of the disease grew, it became apparent that coordination problems were due not only to institutional shortfalls, but also to fundamental diﬀerences in approach and strategy. Amid the apparent ineﬀectiveness of existing approaches to slow the pandemic, notably in the developing world, there was growing consensus that the “epidemic is too complex to be tackled by one single approach” and needed to be “much more multisectoral in its scope.”57 This sat well with the World Bank, the UNDP, UNICEF and the UNFPA, as well as with Mann. However, Mann was forced to leave the WHO in 1990 after a bitter clash with Nakajima, who “paralyzed … [the GPA’s] eﬀorts completely.”58 Mann later established an HIV/AIDS and human rights program at Harvard University,59 but most believe “WHO’s AIDS program pretty much fell apart” after he left.60 Around the same time, the sense of urgency about HIV/AIDS in industrialized countries also started to dissipate. Michael Merson, who succeeded Mann at Director of the GPA, observed: “In the ’90s it became clear we were not going to have a major heterosexual epidemic in the States … [AIDS] was no longer a threat to the West.”61

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On 1 January 1996, the GPA was replaced by UNAIDS, headed by Belgian Peter Piot as Executive Director. The program’s initial six cosponsors (the WHO, UNICEF, the UNDP, the UNFPA, UNESCO and the World Bank) were later joined by the UNHCR, the WFP, the ILO, and the UNODC, to “share responsibility for the development of the programme, contribute equally to its strategic direction and receive from it policy and technical guidance relating to the implementation of their HIV/AIDS activities.”62 The organization is guided by a Programme Coordinating Board consisting of the ten co-sponsors, representatives of 22 governments from all geographic regions, and representatives of ﬁve NGOs, including associations of people living with HIV/AIDS. In public, this was a uniﬁcation of the global eﬀort to ﬁght the disease through “interagency cooperation.” In private, bitter frustration was felt by many GPA staﬀ who felt that almost a decade of eﬀort was being destroyed by international politics. For the WHO, the creation of UNAIDS was an institutional “slap in the face,” an expression of the loss of faith by donor governments in the organization’s capacity to lead a global disease campaign. As a concession, UNAIDS was initially based in WHO headquarters, which remained its “administering agency,” although eventually moving to its own building. Most importantly, the lag time between Mann’s departure and the creation of UNAIDS was seen as costly in human terms, allowing the disease to surge forward, perhaps unstoppably. It is diﬃcult from this point to separate HIV/AIDS activities by the WHO from their incorporation into broader initiatives, a detailed review of which is beyond the scope of this chapter. From the perspective of the WHO, the creation of UNAIDS was a signiﬁcant blow to the organization’s leadership over a global health issue that should have been a clear call for it to assert its mandate. In large part, it was a vote of non-conﬁdence more generally in an organization struggling in the 1990s with its own internal political and bureaucratic problems. As described in Chapter 5, the loss of UNAIDS shook the organization to its core, forcing it to re-evaluate how it saw itself and the role it could play in an increasingly competitive institutional environment. This challenge was taken up by Brundtland, Nakajima’s successor, who sought to “mainstream” HIV/AIDS across all relevant clusters, deﬁned as “the process of analysing how HIV and AIDS impacts on all sectors now and in the future, both internally and externally, to determine how each sector should respond based on its comparative advantage.”63 This suggests a broadening of focus, away from the much-criticized vertical approach which led to the creation of UNAIDS. This was followed in 2003 by a Global Health Sector Strategy for HIV/AIDS

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(GHSS) based on the recognized “need to deﬁne and strengthen the role of the health sector within a broad multisectoral response to HIV/ AIDS.”64 Beyond the WHO, the creation of UNAIDS did little to increase donor commitment to ﬁghting the disease. According to Gellman, UN co-sponsors cut back sharply on the resources and personnel devoted to HIV/AIDS. For example, World Bank loans dropped from $50 million to less than $10 million, WHO spending from $130 million to $20 million, and UNICEF from $45 million to $10 million. Inside UNAIDS, advisers to Piot, spoke of a “syndrome of abdication.”65 An evaluation of UNAIDS in 2002 observed the same: The cosponsors were unenthusiastic, and despite advance notice from 1993 that the GPA would be replaced, took little action to establish real capacity until two or more years after the programme started. Financial arrangements brought cosponsors neither beneﬁts in the form of extra funds, nor their support through commitments to fund. In that sense, the word cosponsor is a complete misnomer.66 The launch of the GFATM (see above) was a belated response to the chronic under-funding of global health in general, and HIV/AIDS in particular. Its separate creation was not a reﬂection of a lack of conﬁdence in UNAIDS, but rather the Fund’s function as a funding mechanism. Since 2002, attention has shifted to improving access to anti-retroviral drugs (ARVs), notably in generic form, by the most aﬀected countries. For the WHO, this shift oﬀered an opportunity for the organization to reassert its technical leadership. Under a new Director-General, Lee Jong-wook, who established his name in tuberculosis control, the WHO declared lack of access to ARVs a “global health emergency” and, with UNAIDS, launched the 3 by 5 Initiative, with the goal of providing three million people living with HIV/AIDS in low- and middle-income countries with life-prolonging ARVs by the end of 2005. For some, the initiative was not only a step back to vertical or disease-focused programs, it was an inappropriate shift by the WHO from a technical to an implementing role: the 3 by 5 initiative is a “top down” unsustainable approach that, without a high level of government investment, fosters dependence on international aid. … The last thing they need is more internationally imposed hurdles that ensure sequestration of ART in costly and ineﬃcient bureaucracies. Countries that have taken

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Global campaigns against disease ownership of their HIV programs have often been the most successful in tackling the epidemic.67

Similarly, Jennifer Prah Ruger and Derek Yach describe the initiative as “a marked shift away from WHO’s broad based mandate and towards strategies for treatment rather than for health promotion. It emphasizes the importance of operational work within countries, though this work is already being undertaken by many others.”68 Jim Yong Kim, Director of the WHO Department of HIV/AIDS, argued in defense that “clear consensus targets are indispensable” and that “time was of the essence”: Those who object to 3 by 5 must address this question: what would be the likely cost if it were never attempted? We can work exclusively to prevent the further spread of HIV, or aim to improve treatment access more slowly, but in the meanwhile high-burden countries will collapse at our feet. Or we can aim for 3 by 5 and move ourselves that much closer to the ultimate goal: preventing all unnecessary deaths from HIV.69 Major donor governments have continued to focus eﬀorts since 2005 on improving access to prevention, treatment, care and support interventions. At the 2005 G8 Summit, world leaders pledged to work with the WHO and UNAIDS towards universal access by 2010,70 a goal endorsed by a High Level Plenary Meeting of the sixtieth UN General Assembly.71 Another key goal has been to improve coordination of eﬀorts across institutions, given a continued proliferation of initiatives. Along with the GFATM and 3 by 5 Initiative, US President George Bush announced a President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, a ﬁve-year initiative worth $15 billion with the aim of delivering antiretroviral treatment to two million people in developing countries.72 Towards this end, a Consultation on Harmonization of International AIDS Funding was held in April 2004 among representatives from governments, donors, international organizations and civil society. The meeting endorsed the “Three Ones” principles which are as follows: One agreed AIDS action framework that provides the basis for coordinating the work of all partners; One national AIDS coordinating authority, with a broad-based multisectoral mandate; and One agreed country-level monitoring and evaluation system.73

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UNAIDS was called on to act as facilitator and mediator in eﬀorts to realize these principles. In 2005 UN agencies and other multilateral and international actors agreed to form a Global Task Team on improving coordination on HIV/AIDS. While the ﬂurry of activity and funding for HIV/AIDS since the late 1990s has been unprecedented, the real impact on addressing the pandemic remains unclear. Worldwide, ﬁnancial resources for addressing HIV/AIDS in low- and middle-income countries have increased markedly. UNAIDS estimates that spending on HIV/AIDS rose from $300 million in 1996 to $8.3 billion in 2005, and reached $10 billion in 2007. Nonetheless, current spending remains far short of what is estimated to be needed, around $15 billion in 2006, rising to $22 billion by 2008. Sustaining and increasing current eﬀorts to meet the need remain signiﬁcant challenges in the ﬁght against HIV/AIDS.74 For the WHO, commitment to increasing access to ARVs has been tempered by tensions between the trade and public health communities. As described in Chapter 5, the stronger protection of intellectual property rights under a growing number of bilateral and regional trade agreements is directly contrary to ﬂexibilities under the Agreement on Trade Related Intellectual Property Rights (TRIPS) that permit the production and import of generic drugs, notably ARVs, to poor countries. The reported exertion of pressure by the US government on the Director-General, which eﬀectively silenced criticism of US bilateral trade agreements,75 was a reﬂection of the WHO’s political impotence in the face of hard power. As Paul Benkimoun writes, [O]nce in the role of Director-General, even if Lee had the personal conviction to resist the US inﬂuence he was given little room for manoeuvre. One example of the pressure put on WHO by the USA concerned the WHO representative in Thailand. The individual in question was sanctioned and recalled after signing an editorial in The Bangkok Post that drew attention to the negative aspects of the bilateral Free Trade Agreement between the USA and Thailand that had been under discussion since 2004. This action was a clear signal of US inﬂuence on WHO. … To obtain US support for 3 by 5 he softened what could have been a more aggressive stand toward the food industry in the Global Strategy on diet, physical activity, and health.76 At the end of 2006, 39.5 million people were estimated to be living with HIV/AIDS worldwide. An estimated 4.3 million people became newly infected with HIV, and nearly 3 million died of AIDS-related

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causes in 2006. Women represent a growing proportion of people living with HIV/AIDS and now comprise nearly half (48 percent) of adults estimated to be living with HIV/AIDS worldwide. Young people under the age of 25 are estimated to account for half of all new HIV infections worldwide.77 Anthony Fauci, senior advisor to the Bush Administration, reports that “For every one person that you put in therapy, six new people get infected. So we’re losing that game, the numbers game … [the disease is] running out of control in parts of Asia and Africa.”78 These grim statistics suggest that the disease continues to outpace the global response, and that the challenge remains as much a social as a biomedical problem.

The polio eradication program: What are the lessons learned? Poliomyelitis is caused by infection with a member of the genus enterovirus known as the poliovirus. It is an acute viral infection primarily spread by the oral–fecal route, with increased risk of infection or severity of the disease associated with immune deﬁciency and malnutrition. Following the successful eradication of smallpox, the disease was identiﬁed as a potential next target because it lacks an animal reservoir and can be prevented through an eﬀective oral polio vaccine (OPV). During the late 1970s, advances in biotechnology brought the potential to radically transform vaccine development. In 1978–79, the US National Institute of Allergy and Infectious Diseases outlined a program to accelerate vaccine development. Then, in 1980 the US Institute of Medicine published two studies that identiﬁed 19 vaccines ripe for development and application in the developing world. Much to the frustration of the international health community, President Ronald Reagan, however, made it clear that vaccine development was not a priority of his administration. In response, a meeting was held at the Rockefeller Foundation’s Bellagio Conference Centre in 1984 in an attempt to reinvigorate international vaccine programs, notably the WHO Expanded Programme on Immunization (EPI).79 The meeting led to the creation of the WHO Programme for Vaccine Development (PVD), as an attempt to utilize advances in biotechnology and better coordinate basic research. Participants at the meeting, including Director of the Smallpox Eradication Programme, D.A. Henderson, immunologist Gustave Nossal and representatives of the WHO, UNICEF, the UNDP and the World Bank, agreed to the creation of the Task Force for Child Survival (TFCS), chaired by former director of the CDC, William Foege, as an eﬀort to overcome institutional rivalries. While the WHO

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was ostensibly the lead UN organization in the health ﬁeld, doubts about its capacity to fulﬁll this role led other institutions to take a more active role. As William Muraskin writes, “Many feared that WHO was like a ‘black hole’ that would absorb and stiﬂe anything that it took into its orbit. The World Health Organization’s support was necessary but its total embrace could be deadly.” A follow-up meeting, known as Bellagio II, was held the following year under the auspices of the TFCS, where Henderson reiterated the need for basic research: “not one of the six vaccines [i.e., polio, tuberculosis, diphtheria, pertussis, tetanus, measles] we are using in the [EPI] programme is fully satisfactory.”80 Amid the international politics that framed vaccine development and application, the call for polio eradication was put forth in 1988 at Bellagio III, and supported by a WHA resolution in 1989 to create the Global Polio Eradication Initiative with the goal of eradicating the disease by 2000. However, how this would be achieved continued to divide the international health community. Concerned that the existing vaccine was good enough for such a purpose, Henderson wrote a proposal for a “Manhattan-Type” project to develop an improved polio vaccine. When the PVD oﬀered little ﬁnancial support, he approached UNICEF, which favored a project for childhood vaccines in general. In 1990 UNICEF’s Jim Sherry met Scott Halstead of the Rockefeller Foundation, who supported the concept of a Children’s Vaccine, a “multi-antigen vaccine against the major child killers, stable at ambient temperature, administered orally, and which produces lifelong immunity when administered as a single dose early in childhood.”81 The concept was immediately ridiculed when presented at the PVD and its Scientiﬁc Advisory Group of Experts (SAGE) for being “science ﬁction.” For his part, Halstead was frustrated at the PVD’s focus on basic research and failure to energize product development. He believed the Children’s Vaccine concept, in contrast, would attract funding. While UNDP and WHO joined forces in June 1990 to form a joint Programme for Vaccine Development, Sherry and Halstead organized an international experts’ meeting in July 1990 that would advise UNICEF about the reasonableness of its funding vaccine research. As Muraskin describes, Setting that meeting up was a complicated and delicate process because of the necessity of muting the powerful rivalries that existed between United Nations agencies, especially UNICEF and WHO. … Conﬂict and competition between UNICEF and WHO had grown severe ever since UNICEF in the early 1980s had

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Global campaigns against disease declared the “Children’s Revolution” and entered the area of promoting children’s health in a direct way—resulting in an increase in turf issues between the two organizations as well as disagreement on style and approach in numerous cases.82

In an eﬀort to build bridges, a conference was held at UNICEF headquarters in September 1990, sponsored by the Task Force for Child Survival. WHO Director General Nakajima was unhappy that the WHO was not in fact the sponsor, and it was agreed that the WHO and UNICEF would co-sponsor. The outcome was “The Declaration of New York: The Children’s Vaccine Initiative,” for which leadership was given to the WHO. There were clear reservations about this decision, notably from Halstead at the Rockefeller Foundation, given the PVD’s perceived ineﬀectiveness at vaccine development, and UNICEF, given its funding of the initiative. More generally, as described in Chapter 5, concerns about the functioning of the WHO were building at this time, leading to the creation of special programs co-sponsored by the WHO but outside of the Director-General’s direct control. Given these concerns, an ad hoc meeting of the Child Vaccine Initiative (CVI) was held at the PAHO in November 1990. While the WHO sought to retain a strong hold over the initiative, it was agreed that the WHO would host the CVI but its Secretariat would retain its formal independence. It was within this context of institutional rivalry that the goal of polio eradication was agreed and pursued by the WHO, UNICEF and partner organizations (such as Rotary International and the CDC) at the World Summit for Children in 1990. When the Global Polio Eradication Initiative (GPEI) was launched, wild poliovirus was endemic in more than 125 countries on ﬁve continents, paralyzing more than 1,000 children every day. Within eight years, considerable progress was achieved. The ﬁrst successes, as in past disease campaigns, were achieved in countries with relatively developed public health infrastructures. In 1991 polio transmission was interrupted in the Americas, and in 1994 the International Commission for the Certiﬁcation of Polio Eradication conﬁrmed the Americas as polio free. This was followed by the Western Paciﬁc Region in 1997. In 1999 the WHA resolved to accelerate the eradication eﬀort,83 and by 2002 the WHO European Region was declared polio free.84 Despite reducing cases by 99 percent, the goal of worldwide eradication was not achieved by 2000, and the disease remained endemic in 17 countries in Africa and Asia (formerly 125 countries). With redoubled eﬀorts, this number was reduced to six countries by 2003—

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Nigeria, Pakistan, India, Niger, Afghanistan and Egypt. However, the risk of re-infection of disease-free areas began to prove a threat to progress. In the Sudan, a new outbreak after three years occurred as a result of conﬂict and migrating populations. As the head of the GPEI, David Heymann warned, “African countries have worked rapidly and eﬀectively to eradicate polio; now the tragedy is that many of them are becoming re-infected.”85 In response, a “New Global Eradication Strategic Plan for the period 2004–8” was submitted to the WHA in 2004 with a revised timeframe for eradication by 2008. In late 2007, this goal remains uncertain. While conﬁrmation that indigenous wild poliovirus transmission had been stopped in Egypt and Niger, reducing the number of endemic countries to four,86 new outbreaks occurred in northern Nigeria, where Islamic states suspended immunization, based on claims that the vaccine causes sterility and was a US plot to spread HIV infection, and in Uttar Pradesh, India resulting in an increase in global cases in 2006.87 Concerns about the “excessive dosing of children with OPV” have been expressed, as well as accusations of the inﬂation of polio as a public health problem.88 And, as with other global disease programs, there is a substantial gap in required funding, estimated by WHO at $390 million for 2007–8.89 Since 1988, two billion children worldwide have been immunized against polio at a cost of $3 billion. Achieving eradication in the ﬁnal countries will require concerted political and economic eﬀorts. Thus, after almost 20 years of eﬀort, the GPEI is balanced between success and failure.

Conclusion For many, including powerful donors and the general public, global disease campaigns to prevent, control, treat and, if possible, eradicate speciﬁc diseases epitomize the expected role of a world health organization. Where a disease aﬀects a high proportion of the population, and is signiﬁcantly impacting on a society’s social and economic development, there are clear utilitarian and humanitarian rationales for such eﬀorts. Moreover, there is political seductiveness in mass disease campaigns. As well as having great public appeal, they can attract major ﬁnancial resources and, if successful, greatly enhance the status and reputation of an organization. Disease control and eradication ﬁres the public imagination, allowing organizations to point to concrete successes. Failure, however, brings equal amounts of criticism. The WHO’s battle against speciﬁc diseases over the past six decades has yielded a mixture of successes and failures. The organization’s early

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eﬀort to eradicate malaria was a resounding failure, while the smallpox campaign that followed remains the WHO’s most celebrated achievement. Between these two extremes are many other diseases which the organization has sought to address, with varying degrees of eﬀectiveness. As suggested by the large number of programs maintained, disease-focused activities remain a signiﬁcant part of the WHO’s work. Global campaigns have been the most high proﬁle, but there are many other programs that receive limited attention. For the purposes of this analysis, global disease campaigns provide insights into the complex institutional, technical and political challenges inherent within the WHO’s mandate to promote and improve the world’s health. Campaigns can bring much-needed support, but can also result in harsh criticism from many directions when expectations fail to be met. An emphasis on technical solutions, such as insecticides, vaccines and drugs (so-called “magic bullets”), with insufﬁcient attention to the social context within which diseases occur and spread, is also a feature of less-successful campaigns. Finally, how campaigns have faired reveals much about the WHO itself. The battle, for example, over the CVI reﬂects the institutional rivalries that have characterized the global health community over recent decades. Rivalries between the WHO and other international organizations concerned with health reﬂected an increasingly competitive policy environment, with leadership over disease-focused programs a sought-after political currency. The similar ﬁght, eventually lost, to lead global eﬀorts to ﬁght HIV/AIDS was, in large part, a result of diﬀerent perspectives over the balance between biomedical and broader approaches to diseases. The mixed record of success and failure was, in part, a reﬂection of the limitations of the WHO and, perhaps more signiﬁcantly, of the biomedical approach per se. Global disease campaigns, in themselves, fell far short of fulﬁlling the WHO’s mandate of improving world health.

4

Tackling the broad determinants of health

Despite the often cited deﬁnition in the Constitution of the WHO, of health as “more than the absence of disease,” disease-focused programs have been the focus of the organization’s largest programs. As described in Chapter 3, mass disease campaigns against selected communicable diseases have been a mainstay of the WHO’s activities over the past six decades. The historic eradication of smallpox, along with other notable successes such as yaws, resulted in calls to tackle other diseases in a similar manner. This has been tempered, however, by less successful eﬀorts against malaria, HIV/AIDS and other diseases posing major public health threats. Indeed, by the late 1960s, disappointing health gains from some disease campaigns, accompanied by increasing awareness of the limited capacity of health services to take over such campaigns in the developing world, cast doubt that they were likely to be time limited. Longer-term strategies were needed to improve health than the targeting of individual diseases. This chapter examines the attempts by the public health community, as it impacted on the WHO’s work, to redress the neglect of social medicine by addressing the broad determinants of health. Determinants of health are “the range of personal, social, economic and environmental factors that determine the health status of individuals or populations.”1 These factors can be grouped into the broad categories of “socio-economic environment; physical environments; early childhood development; personal health practices; individual capacity and coping skills; biology and genetic endowment; and health services.”2 For the WHO, the initial focus of its activities was individual factors, while broader environmental or structural factors have been given limited attention. This led to a movement within the organization, and international health in general, to address the causal (i.e. upstream) factors contributing to health status, rather than treating the direct (i.e.

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downstream) manifestation of ill-health. Initially, this reaﬃrmed that the health of individuals and communities is strongly inﬂuenced by factors such as income, housing, employment, food and education, echoing the social medicine movement from the nineteenth century. From the 1980s, issues of equity of access to these basic requirements within and across societies received growing attention among scholars and policy makers in health development. More recently, additional attention has been given to broader factors, such as development, trade agreements and state–market relations. Importantly, these diﬀering foci have been more than intellectual debates, but have had implications for the allocation of WHO resources and eﬀorts. To understand how wider political, economic and ideological shifts towards eﬀorts to address the broad determinants of health have inﬂuenced WHO activities, this chapter describes a number of key initiatives—Health for All, International Code on the Marketing of Breast Milk Substitutes, the Model List of Essential Medicines, Framework Convention on Tobacco Control (FCTC) and the Commission on the Social Determinants of Health. Many of these initiatives have already been the subject of detailed analysis elsewhere. Along with a brief description of these important initiatives, this chapter locates them within the WHO’s struggle to ﬁnd an appropriate balance between disease-targeted interventions and the intransigent underlying factors that contribute to ill-health. Negotiation of the terrain between these two fundamentally diﬀerent approaches, and their underlying values, remains a source of ongoing tension within the organization.

Back to basics: the primary health care movement The downturn in the world economy during the 1970s brought recession, increased debt for oil-importing low- and middle-income countries (LMICs), and strained public ﬁnances. This prompted a rethinking of development theory which challenged investment in large-scale infrastructure projects aimed at replicating the models of economic growth of western industrialized countries. This shift in the development paradigm was accompanied by a greater assertiveness by LMICs in world politics embodied in the Non-Aligned Movement, and calls for a New International Economic Order (NIEO). The core idea driving this movement was the desire to challenge the status quo, namely the structural inequalities embedded within a world economy that maintained LMICs at the “periphery” and industrialized countries at the “core.” It was argued that the post-war order was inherently

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favorable to certain countries, and needed to be fundamentally renegotiated to enable the developing world to advance. Within the health sector, many newly independent countries adopted the western medical model, either as part of their colonial past or as a post-war extension of the modernization theory of development. Health care systems based on this medical model may emphasize hospital-based treatment of patients by health professionals, curative care, and high-technology interventions. There were notable exceptions such as the Bhore Commission in India, which was set up by the government in 1943 to make recommendations on the planning of health services’ delivery in order to improve health, including primary health care.3 Similarly, Richard Titmuss was appointed by the government of Tanganyika to carry out studies in 1961–62 that would help plan the development of health services.4 Nonetheless, health sector aid, like much development assistance of the time, focused on major infrastructure projects such as building hospitals and medical schools. The health care systems of many newly independent countries, in turn, evolved to reﬂect the western-based model, and its allocation of ﬁnancial and human resources. By the 1970s, it was clear that this model of health care was failing to meet the basic needs of populations in poor countries. Moreover, the diﬃcult economic climate of the 1970s in many parts of the developing world created signiﬁcant pressures on public expenditure, and the western model of health care was increasingly unaﬀordable. While health expenditure as a percentage of gross domestic product (GDP) remained relatively stable during 1970–89 in OECD countries,5 health resources in many LMICs were severely strained by growing levels of foreign debt, declining terms of trade and economic recession. In such resource-constrained conditions, there was a need to ﬁnd aﬀordable, low-cost and appropriate technologies suitable for the particular needs of LMICs. Alternative approaches to health care began to be shared by community-based health workers in Latin America, Bangladesh and the Philippines, and the so-called “barefoot” doctors of China, who received basic training to work in rural settings. The health gains achieved in low-income settings, notably Cuba and Kerala, India, also demonstrated the capacity to improve public health with limited resources. Books such as Health and the Developing World by John Bryant,6 Health by the People by Kenneth Newell,7 and Doctors for the Villages: Study of Rural Internships in Seven Indian Medical Colleges by Carl Taylor8 played an inﬂuential role. As Bryant noted, “the most serious health needs cannot be met by teams with spray guns and vaccinating syringes.”9

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In 1975, the WHO and UNICEF published the widely discussed report Alternative Approaches to Meeting Basic Health Needs in Developing Countries. UNICEF was going through a period of reﬂection on its mandate and strategy. The organization focused on meeting the emergency needs of children largely in post-Second World War Europe. This shifted to addressing the longer-term needs of children in LMICs and, from the early 1960s to mid-1970s, emphasis broadened further to the meeting of children’s intellectual, social and emotional needs. Simultaneously, the organization expanded its role in advocacy and technical assistance. An attempt was made to meet essential human needs by developing a set of interrelated services, an approach known as the “Basic Services Strategy.” Within the WHO, a new Director-General, Halfdan Mahler (Box 4.1), with extensive experience of working at diﬀerent levels of the organization on tuberculosis control, along with a long-time commitment to social justice, led to the proposed goal of “Health for All by the Year 2000” at the WHA in 1976. In his speech to the Assembly, he stated: “Many social evolutions and revolutions have taken place because the social structures were crumbling. There are signs that the scientiﬁc and technical structures of public health are also crumbling.”10

Box 4.1

Halfdan Mahler

Halfdan Mahler of Denmark remains the most respected among WHO directors-general because of his championing of the Health for All and primary health care movement. Born in 1923 and trained in medicine, he began his international career in 1950–51 when he directed a Red Cross anti-tuberculosis campaign in Ecuador. In 1951 he began a 10-year stint in India as Senior WHO Ofﬁcer attached to the National Tuberculosis Programme. He served as Chief of the Tuberculosis Unit at WHO Headquarters in Geneva from 1962 to 1969, before being appointed Director, Project Systems Analysis, a program that implied improving national capabilities in health planning. In 1970, he was made an Assistant Director-General while retaining his Project Systems Analysis post. In 1973, while occupying that position, Dr Mahler was elected the WHO’s third Director-General. He was re-elected for two further ﬁve-year terms in 1978 and 1983, before retiring in 1988. Mahler’s style of leadership, described as charismatic and energized by a missionary zeal, was inﬂuenced by his father, who

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was a Baptist preacher. He combined sound technical knowledge with a strong moral commitment to social justice. His initiation of the Health for All and Primary Health Care movements stemmed from this background and remains his most prominent legacy. Mahler also demonstrated personal courage when he turned his attention to the problem of access to essential medicines and the regulation of the baby food industry, taking on two powerful industries in succession. While the initiatives were supported by almost all member states, they led the US government to include the WHO in its accusations that certain UN bodies were becoming inappropriately politicized. Pressures arising from the freezing of the WHO’s regular budget followed. The election process in 1988 led to the retirement of Mahler, who subsequently conceded that he would have run again had he realized the level of support behind him. Source: Compiled from Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care,” American Journal of Public Health 94, no. 11: 1864–74 (2004).

Recognizing their convergent thinking on health development, Mahler and UNICEF Director Henry Labouisse hosted the landmark International Conference on Primary Health Care in Alma Ata, Kyrgyzstan in September 1978. The conference remains “a major milestone of the twentieth century in the ﬁeld of public health.”11 Adopting the goal of Health for All, the conference called for a revolution in thinking about health development, rejecting top-down, high-tech and vertical (disease-focused) approaches in favor of accessible, integrated care that recognized the key role of local communities, aﬀordable and appropriate technologies, and the need to address the underlying political, social and economic causes of poor health. The strategy to achieve all of this was identiﬁed as primary health care (PHC), shifting the focus from large urban hospitals to local health providers as the ﬁrst point of contact—general practitioners, nurses, pharmacists, social workers and other health providers within communities. Importantly, the strategy also embraced the role of citizens and communities, including local government and civil society organizations (CSOs). In short, PHC sought to shift emphasis from a top-down to a bottom-up approach, and from vertical (disease) to horizontal (integrated) health care. The conference, attended by 134 out of 158 member states, unanimously endorsed the Declaration of Alma Ata (Box 4.2).

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Box 4.2

Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978

The International Conference on Primary Health Care, meeting in Alma-Ata this twelfth day of September in the year Nineteen hundred and seventy-eight, expressing the need for urgent action by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world, hereby makes the following

Declaration I The Conference strongly reafﬁrms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or inﬁrmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries. III Economic and social development, based on a New International Economic Order, is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries. The promotion and protection of the health of the people is essential to sustained economic and social development and contributes to a better quality of life and to world peace. IV The people have the right and duty to participate individually and collectively in the planning and implementation of their health care. V Governments have a responsibility for the health of their people which can be fulﬁlled only by the provision of adequate health and social measures. A main social target of governments, international organizations and the whole world community in the coming decades should be the attainment

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by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice. VI Primary health care is essential health care based on practical, scientiﬁcally sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the ﬁrst level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the ﬁrst element of a continuing health care process. VII Primary health care: 1 reﬂects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience; 2 addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly; 3 includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs; 4 involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and

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Tackling the broad determinants of health other sectors; and demands the coordinated efforts of all those sectors; 5 requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate; 6 should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need; 7 relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community. VIII All governments should formulate national policies, strategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will, to mobilize the country’s resources and to use available external resources rationally. IX All countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and beneﬁts every other country. In this context the joint WHO/UNICEF report on primary health care constitutes a solid basis for the further development and operation of primary health care throughout the world. X An acceptable level of health for all the people of the world by the year 2000 can be attained through a fuller and better use of the world’s resources, a considerable part of which is now spent on armaments and military conﬂicts. A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share. The

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International Conference on Primary Health Care calls for urgent and effective national and international action to develop and implement primary health care throughout the world and particularly in developing countries in a spirit of technical cooperation and in keeping with a New International Economic Order. It urges governments, WHO and UNICEF, and other international organizations, as well as multilateral and bilateral agencies, nongovernmental organizations, funding agencies, all health workers and the whole world community to support national and international commitment to primary health care and to channel increased technical and ﬁnancial support to it, particularly in developing countries. The Conference calls on all the aforementioned to collaborate in introducing, developing and maintaining primary health care in accordance with the spirit and content of this Declaration. Source: WHO, Declaration of Alma-Ata, International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978, www.who.int/hpr/NPH/ docs/declaration_almaata.pdf.

Importantly, there was a clear normative basis to the PHC movement, namely a commitment to social equity in the provision of health services, based on recognition of health as a human right. It was argued that equity in health was a fundamental or overriding goal, for both utilitarian (public health is best protected through universal access to health care) and humanitarian (health is a fundamental human right) reasons. This goal, in turn, was seen as best achieved through the PHC strategy, which focused on the provision of health care to all on the basis of need rather than entitlement. Criticism of the PHC approach arose almost immediately after the conference, in part, focused on the ideas and values underpinning it. Conservative attitudes among health professionals led to perceptions of PHC as anti-intellectual and non-scientiﬁc in its proposed solutions to health problems. Others focused on the feasibility of implementing PHC. Some decried the political naivety of the movement, doubting the revolutionary potential of community-led action. Others challenged the goals of comprehensive PHC as too ambitious and, given resource constraints in LMICs, still too costly. Indeed, the rise of neoliberalbased ﬁscal policies brought even greater restrictions on public spending on health. How could poor countries in the developing world, it

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was argued, aﬀord to implement health for all? From the perspective of major donor countries, faced with budgetary constraints of their own, PHC was a potential bottomless pit for health sector aid.12 Perhaps most challengingly, it was argued that strategic thinking was still needed to take the initiative forward. Given limited resources and an inability to do everything at once, what primary care services should receive priority within the overall strategy? In 1979, the Rockefeller Foundation hosted a meeting in Bellagio, Italy entitled “Health and Population in Development” which included discussion of the ideas later published in a seminal paper13 by Julia Walsh, then Assistant Professor at New York University and Kenneth Warren, Director of Health Sciences at the Rockefeller Foundation. While Walsh and Warren argued that the goals of Alma Ata were “above reproach,” they argued the need for an “interim strategy” targeting selected disease prevention and treatment interventions on the basis of prevalence, morbidity, mortality and feasibility (namely eﬃcacy and cost-eﬀectiveness). This strategy, which became known as selective primary health care, was adopted soon after by UNICEF in the form of four vertical programs: growth monitoring, oral rehydration therapy (ORT), breastfeeding and immunization. Three further priorities—family planning, female education and food supplementation—were subsequently added to become collectively known as GOBI-FFF. UNICEF Executive Director James Grant used the strategy as the platform for declaring a “children’s revolution.” Urged on by Jonas Salk, who had developed the polio vaccine, and World Bank President Robert McNamara, Grant supported the acceleration of the EPI in collaboration with a consortium of donor agencies including the Rockefeller Foundation and USAID (see Chapter 3). By 1990, 80 percent immunization rates were being achieved, and reductions in child mortality doubled in many LMICs. Marcos Cueto describes the example of Colombia, where only 9 percent of children were covered by the DPT vaccine (for diphtheria, pertussis and tetanus) in 1975. This increased to 87 percent by 1990.14 Despite such accomplishments, Walsh and Warren’s strategy of applying low-cost technical interventions to tackle the main disease problems of LMICs sparked what Lesley Magnussen et al. describe as “more than two decades of exhaustive debate.”15 The paper attracted a spate of negative letters upon publication,16 and the controversy over selective or comprehensive PHC continues to the present day. Supporters of Health for All argued that comprehensive PHC was not given suﬃcient time to take eﬀect. They pointed to notable successes during the 1980s, such as Mozambique, Cuba and Nicaragua, where expanded

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PHC coverage yielded improved population health indices.17 The WHO responded to the charge that comprehensive PHC had no clear targets by publishing a number of reports18 which provided measurable indicators. However, the reports appear to have been largely ignored amid growing tensions between the WHO and UNICEF. Kenneth Newell, the architect of the WHO’s comprehensive PHC strategy, described selective PHC as a “threat” and “counter revolution.”19 Others argued that the technocratic approach of selective PHC simply reverted back to the biomedical approach, thus diverting attention from the broad determinants of health. One cited example was ORT, widely promoted by UNICEF to reduce the millions of childhood deaths from diarrhea. Many diﬀerent commercially manufactured products became available, requiring the user to read and follow instructions carefully. Ingesting a product with too little water added could increase dehydration, and thus the risk of death. Most deaths from diarrhea occur among the poor and illiterate, thus making ORT both expensive and subject to erroneous use. Moreover, ORT requires access to clean water, not available in many communities where ORT was promoted without corresponding large-scale investments in improving water and sanitation. David Werner, author of the seminal book, Where There Is No Doctor,20 saw UNICEF’s sudden shift to selective PHC as a bowing to pressure from the US government which dismissed Health for All and PHC as “too political.”21 Instead of improving child health, he writes, the failure of the international community to address the broad determinants of health led to an increase in child deaths from malnutrition in the developing world during 1991–96, as well as a resurgence of “diseases of squalor such as cholera, tuberculosis and plague.”22 For many, Grant’s penchant for generating positive publicity for the organization smacked of “showboating.” UNICEF was seen as selfpromoting, selectively picking the “low hanging fruit” (i.e. relatively easier tasks) among the many health needs of LMICs, and thus allowing the organization to point to measurable results (e.g. child immunization rates). This gave priority to interventions that yielded good photo opportunities but did little to address the need for rational priority setting. The shrewd, media-friendly approach used by Grant, including the appointment of high-proﬁle ambassadors and the annual sale of Christmas cards, earned the organization much credit. The Convention on the Rights of the Child was then adopted in 1989, followed amid much fanfare by the World Summit for Children in 1990, which was attended by 71 heads of state and representatives from 159 countries. Within the public health community, many felt frustrated

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with UNICEF’s selective approach, which left the WHO to tackle the more intransigent and systemic health problems across all age groups in the developing world.23 Intense rivalry between the EPI and CVI (see Chapter 3) spilled over into other areas. In the battle between selective and comprehensive PHC, the WHO’s own internal shortcomings became visibly apparent. Public comparisons of the two organizations were neatly summarized in a popular saying within the development community that “WHO knows everything, but does nothing” while “UNICEF knows nothing but does everything.” There was a small consolation—the UNDP fared even worse, seen as knowing nothing and doing nothing. The ascendance of the World Bank in health development, described in Chapter 5, proved a further setback to implementing PHC. The conditionalities introduced, as part of structural adjustment programs (SAPs), by the World Bank and International Monetary Fund (IMF) required austerity measures to be adopted by many LMICs, including cuts in public spending on health. Borrowing countries were also required to adopt neoliberal-based health sector reforms (e.g. cost recovery, privatization) whose underlying principles sat directly contrary to the equity-based values of health for all.24 During the 1990s, further emphasis was placed on setting priorities based on disease burden and the cost-eﬀectiveness of key health interventions, with the aim of identifying an “essential package” that resource-constrained governments should provide.25 This approach was explicitly an extension of Walsh and Warren’s selective PHC strategy. The election of Hiroshi Nakajima in 1988 (Box 4.3) as DirectorGeneral marked what Cueto describes as “the end of the ﬁrst period of primary health care.”26 By the early 1990s, the prospects for achieving Health for All by the Year 2000 looked gloomy at best. Not only had the anticipated revolution in health development not occurred, its basic tenets found little companionship in the hard-nosed neoliberalism that had come to permeate many international organizations, including the World Bank and IMF, along with many bilateral aid agencies. Downsizing of the public sector through privatization, deregulation and other market-friendly policies, became the order of the day. In the health sector, this translated into policies seeking additional sources of ﬁnancing (e.g. cost recovery, private and social insurance schemes), the creation of a public-private mix in health care provision, the introduction of market-based incentives to improve public sector performance, and the identiﬁcation and prioritization of cost-eﬀective interventions. As health sector reforms swept the world, LMICs were pressed to make their health systems leaner and meaner.27

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Box 4.3

83

Hiroshi Nakajima

Born in Chiba, Japan on 16 May 1928, Hiroshi Nakajima received his medical degree from Tokyo Medical University. His career eventually focused on pharmacological research, and he worked for 10 years with psychiatrist Jean Thuillier in France on the new science of psychopharmacology before joining the WHO in 1974 as a scientist in the Drug Evaluation and Monitoring program. In 1976, he became Chief of the Drug Policies and Management Unit, where he played an important role in developing the concept of essential drugs. In 1978, the Regional Committee for the Western Paciﬁc Regional Ofﬁce elected him as Regional Director, an ofﬁce he held for two consecutive terms until 1988. Nakajima was then elected Director-General of the WHO in 1988 and re-elected for a second ﬁve-year term in 1993. During his time in ofﬁce, Nakajima remained a controversial leader. Following on from the charismatic style of Mahler, his lack of presence and language skills led to concerns about his ability to represent a major international organization. His mishandling of a press conference, amid an outbreak of plague in Surat, India in 1994, seemed to demonstrate this. Internal conﬂict with key WHO staff added to these concerns. The most prominent was his clash with Jonathan Mann, head of the Global Programme on AIDS, which led to Mann’s departure in 1990. Nakajima’s successful reelection campaign in 1993, largely with the support of Asian and developing countries, led to further controversy. In Europe, there were accusations from governments that the organization had awarded contracts to bolster his chances for re-election. A few developing countries reported threats from Japanese ofﬁcials that aid and trade would be affected if they did not support Tokyo’s candidate. During his second term, the WHO under Nakajima drew growing criticism, notably from the United States, European and African countries. Amid broader American disaffection with the UN system, the Bush and Clinton administrations accused Nakajima of being unwilling to cut budgets or use the organization’s resources more efﬁciently to meet new health challenges such as tuberculosis, AIDS, maternal and child health, growing resistance to antibiotics, and polio eradication. It was argued that Nakajima did not want to upset entrenched programs, medical constituencies

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Tackling the broad determinants of health or the priorities of one country or region. This period saw major donors create new global health initiatives that increasingly sidelined the WHO. Nakajima also ran into difﬁculty with African countries after he reportedly raised questions about the qualiﬁcations of African candidates for WHO appointments, creating ill-will among countries that had earlier supported him. In 1997, Nakajima announced that he would not seek a third term, in the interests of the organization. The ensuing election process was conducted with greater openness, with more than four nominees for the post for the ﬁrst time in the organization’s 50-year history, and a desire among member states to review the internal governance of the WHO. Sources: Barbara Crossette, “U.N. Health Ofﬁcial, Opposed by U.S., Won’t Seek Re-election,” New York Times, 1 May 1997; Fiona Godlee, “Who should be the next head of the WHO?” BMJ 316 (3 January 1998): 4–5.

The key voice that might have spoken out against this rising tide of neoliberal economism, the WHO, was hampered by its own internal problems, notably weakened leadership with the departure of Mahler. As described in Chapter 5, in a world increasingly focused on the “bottom line” and “value for money,” the WHO was increasingly overshadowed by other organizations, such as the World Bank, with its substantial lending (and hence political) power, and a growing number of new global health initiatives. Health for All was out of step, it seemed, with the political ideology of the day. Under Nakajima, eﬀorts to reinvigorate Health for All, rephrased with a less ambitious timeframe of “Health for All in the 21st Century,” were initially subsumed within internecine disputes. In 1996 Derek Yach, formerly of the South African Medical Research Council, was put in charge of Renewing the Strategy for Health for All. He fell out of favor with Nakajima soon after and was unceremoniously moved, from near the DirectorGeneral’s oﬃce, to an obscure corner of the Geneva headquarters. Nakajima’s eﬀorts to reinvigorate Health for All were also out of step with new priorities supported by major donors, led by the US government, many of which were focused on individual diseases. Throughout the 1970s and 1980s, tuberculosis had continued to kill millions annually in the developing world, but international eﬀorts to tackle the disease were eclipsed by other priorities. Its resurgence in industrialized countries, along with the growing incidence of multi-drug resistant

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tuberculosis and links between tuberculosis and HIV/AIDS, prompted calls for renewed attention to the disease. In 1993 the WHO declared tuberculosis a “global emergency”. Over the next 10 years, several new initiatives were supported by donor countries such as the Stop TB Partnership, TB Alliance, and GFATM, in some of which the WHO has been a participant. Similar initiatives to tackle HIV/AIDS, malaria and other diseases were created by donor countries during this period. The change in leadership in 1998 saw the renewal process restarted, as Brundtland sought to recapture Mahler’s ethical and moral leadership in international health. Visualizing the WHO as “the world’s health conscience,” she promoted Yach back to a senior management position and called for the WHO to support a “universal health for all value system” based on human rights, equity, ethics and a gender perspective. She was supported in this stance by CSOs which looked to the WHO to counterbalance the World Bank. For example, in an editorial in the BMJ Zafrullah Chowdhury and Michael Rowson of the People’s Health Assembly (PHA) called on the WHO to “assert its principles once more” and to “act as a beacon of hope in turbulent times.”28 Brundtland responded by describing the WHO’s commitment to “increasing resources to improve health for the world’s 3 billion poor people.”29 Reconciling the core values underpinning Health for All and PHC, namely health as a human right and social justice, with the continued dominance of neoliberal economism and disease-focused initiatives among major donor agencies, remains a major challenge.30 Following the departure of Brundtland, CSOs have continued to call for the WHO to reassert its leadership by championing these values. Evidence of increasing and persistent health inequalities within and across countries since the late 1980s has been the most signiﬁcant challenge to neoliberal policies. William Foege summarizes public health in the twentieth century as “spectacular accomplishments, spectacular inequities.” During the second half of the century, life expectancy in the developing world rose from 40 to 64 years, and infant mortality declined from 123 to 60 per 1,000 live births. On this basis, he concluded that “There is no longer a question of whether it is possible to organize eﬀective international health programs.”31 Disaggregated ﬁgures, however, reveal stark inequities. For example, the impact of HIV/AIDS has been hardest on the African continent, leading to a decline in life expectancy: [I]nequality in mortality between continents began to rise shortly after inequality in gross domestic product per capita began to diverge most clearly. This association could reﬂect the profound

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Tackling the broad determinants of health impact of AIDS on one continent, Africa. AIDS is a disease of the poor, and global inequality in wealth will have compounded the eﬀect of AIDS on Africa. … 32

Similarly, Jennifer Prah Ruger and H.J. Kim conclude that “[i]nequalities in child and adult mortality are large, are growing, and are related to several economic, social and health sector variables. Global eﬀorts to deal with this problem require attention to the worse-oﬀ countries, geographic concentrations, and adopt multidimensional approaches to development.”33 How best to address health inequalities, however, has kept the debate over comprehensive or selective PHC active to the present. A strong emphasis on disease-focused programs has continued to shape WHO activities. As Magnussen et al. conclude, [a]fter several years of investment in vertical interventions, preventable diseases remain a major challenge for developing countries. The selective model has not responded adequately to the interrelationship between health and socioeconomic development, and a rethinking of global health policy is urgently needed.34

Figure 4.1 Former directors-general (Brundtland, Mahler, Nakajima) and then serving Director-General (Lee) at the 25th Alma Ata Celebration in 2003. Source: www.who.int/dg/lee/almaata_celebration/en/index.html, Picture.

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Taking on big business: strengthening the global regulation of drugs, baby milk and tobacco Along with the PHC strategy to achieve Health for All, eﬀorts to address the broad determinants of health turned the WHO’s attention to health-related products. During the 1970s, it was recognized that health could be enhanced or harmed by access to certain products. The rational use of medicines, for example, is dependent on their eﬃcacy, appropriate use, quality and aﬀordability. The healthy feeding of infants is inﬂuenced by parents, but also by the appropriateness of marketing practices by manufacturers of breast milk substitutes. Morbidity and mortality from smoking-related diseases are shaped by an individual’s decision to smoke, but also by the supply and marketing of tobacco products. Each of the industries involved—pharmaceuticals, food and tobacco—represent powerful economic interests whose regulation, prior to the 1970s, the WHO had limited engagement with. Until the 1970s, traditional health promotion largely focused on the demand for such products, and hence, changing individual behavior through, for instance, health education and public information. As the WHO gave attention to regulating the supply of these products, it moved into unfamiliar terrain, bringing the organization into direct conﬂict with powerful economic and political interests. International Code on the Marketing of Breast Milk Substitutes In the late 1960s, following a downturn in sales of infant milk in highincome countries, food companies began to aggressively promote their products in LMICs. In 1968 Derrick Jelliﬀe coined the term “commerciogenic malnutrition” to describe the health impact of this “revolution in infant feeding practices.”35 Lack of hygiene, high cost and the inferiority of products to breast milk meant that the increased use of manufactured products led to a corresponding rise in infant morbidity and mortality in the developing world. Alarming evidence began to accumulate, largely from CSOs, of the number of infant deaths attributable to the marketing of breast milk substitutes. In Chile, for example, “post-neonatal deaths were signiﬁcantly more frequent (relative risk, 3 to 1) among infants who started bottle feeding in the ﬁrst three months than among those exclusively breast-fed during that time.”36 In 1974 War on Want published The Baby Killer, a report on infant malnutrition and the promotion of artiﬁcial feeding in the Third World. The Swiss NGO Bern Third World Action Group (AgDW) translated the report with the title Nestlé Kills Babies, and was

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consequently sued for libel by Nestlé. The lawsuit catalyzed a CSO-led campaign, against Nestlé and other food companies, which called for international regulation of the industry. The WHO’s role in this campaign began with the adoption of a resolution by the twenty-seventh WHA in 1974, calling for a review of the promotional activities of infant formula manufacturers, and the imposition of remedial measures such as advertising codes and legislation.37 While advocacy continued, highlighted by a CSO-led boycott of Nestlé, a joint WHO/UNICEF meeting on Infant and Young Child Feeding was held in 1979 which recommended that “there should be an international code of marketing of infant formula and other products used as breast milk substitutes.” Over 150 health representatives from various governments and CSOs agreed a set of recommendations that would support and promote breast feeding. The food industry ignored most of the recommendations, prompting WHO Director-General Mahler to state: “There is no way industry can get away with what they have been doing in the past and say they have our blessing.”38 In May 1980 the thirty-third WHA requested that the DirectorGeneral prepare a code “in close consultation with Member States and with all other parties concerned.”39 The debate over the code in May 1981 has been described as “one of the most dramatic moments in the history of international health.”40 The food industry lobbied furiously to prevent the adoption of the code, with Nestlé seating its own attorney on the Guatemalan delegation until his credentials were challenged by the WHO Secretariat. Despite industry objections, on 21 May 1981 the WHA adopted the International Code on the Marketing of Breast Milk Substitutes by 118:1:3 vote (the United States was the lone objecting member state). The Preamble recognizes that “the marketing of breast milk substitutes requires special treatment, which makes usual marketing practices unsuitable for these products.” The aim of the Code is “to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by the proper use of breast milk substitutes, when they are necessary, on the basis of adequate information and through appropriate marketing and distribution.” The Code does not restrict the availability of substitutes for breast milk, nor prevent mothers from deciding to use them. When properly implemented, the Code will protect breastfeeding and non-breastfeeding families, as well as health workers, from unethical marketing practices. Since then, the WHA has passed resolutions that “clariﬁed and strengthened” certain provisions of the Code, particularly Article 2 (Scope) and Article 6 (Health Care Systems), which deals with free and low-cost supplies of substitutes for breast milk.

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Overall, the Code was an unprecedented action within the UN because it was the ﬁrst time that member states of an organization voted in favor of controlling the actions of a transnational industry. Perhaps even more signiﬁcant was that the two lead agencies—the WHO and UNICEF—acted to curtail the industry’s behavior as part of their mandate to protect and promote public health. However, the issue fuelled criticism of the organization by the US government and corporate sector, adding to pressure already exerted in protest at the WHO’s support of the Model List of Essential Medicines (see below). Some saw the WHO as succumbing to “politicization,” similar to developments in the UN Conference on Trade and Development (UNCTAD), and UNESCO.41 For supporters, it was a landmark example of the importance of tackling the broad determinants of health. The Model List of Essential Medicines In 1977 the WHO adopted the ﬁrst Model List of Essential Medicines, a list of 208 individual medicines which together could provide safe, eﬀective treatment for the majority of communicable and non-communicable diseases. Essential medicines are deﬁned as “those that satisfy the priority health care needs of the population.” They are selected with due regard to disease prevalence, evidence on eﬃcacy and safety, and comparative cost-eﬀectiveness. The challenge for member states is to ensure such medicines are “available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can aﬀord.”42 In principle, the creation and maintenance of the Model List could be seen as a largely technical, and hence, uncontroversial exercise. Since 1897, when aspirin was introduced as the ﬁrst synthetic pharmaceutical, tens of thousands of medicines have been introduced worldwide. In any country, irrational use can arise from poor quality control, inappropriate prescribing, and economic cost. In some countries, clinicians may face a bewildering range of commercially supplied and marketed medicines, yet have limited access to independent advice about their eﬃcacy, safety and cost-eﬀectiveness. Such problems can be especially notable in the developing world, where governance of pharmaceutical supply and use can be weak or non-existent. Moreover, pharmaceuticals account for a larger proportion of the scarce health resources available in LMICs, representing between 25 and 66 percent of total public and private health spending, thus making rational use of medicines even more important.43

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Despite a clear practical need for a Model List, in practice its initial creation and subsequent maintenance has faced ongoing political hurdles. The problems of irrational use of medicines in the developing world were ﬁrst raised at the WHA in 1975 by Director-General Mahler, who drew attention to the adverse eﬀects of certain drugs, unethical marketing practices, and the powerful inﬂuence of transnational pharmaceutical companies. The developing world oﬀered the industry a rapidly growing market, with many countries, such as Thailand and Bangladesh, spending substantial proportions of their health budgets on drugs with uncertain beneﬁt. In addition, many drugs were imported at high cost, making them unaﬀordable to the poor. This situation was aggravated by a lack of independent information and inadequate regulatory controls. As Masuma Mamdami writes, “the drugs picture that emerged in the 1970s was of an excessive waste of resources in the third world.”44 In response, the WHA requested that the Secretariat draw up a list of “essential drugs.” In 1977, the WHO produced its ﬁrst Model List of Essential Drugs, later renamed the Model List of Essential Medicines, which has since been revised every two years. Member states, in turn, were encouraged to adopt the list, adapting it to create their own national essential drugs lists. At the time, only a few LMICs (e.g. Peru, Sri Lanka, Tanzania), and only around a dozen countries worldwide, had such a list in place.45 The following year, the WHA adopted a resolution urging member states to adopt national lists of essential medicines and adequate procurement systems. Importantly, the Alma Ata Declaration also designated “the provision of essential drugs” as one of the eight pillars of PHC. Although described by the ﬁrst Director of the WHO Action Programme on Essential Drugs (APED), responsible for implementing the Model List, as a “peaceful revolution in international public health,”46 there was immediate and signiﬁcant opposition from the pharmaceutical industry and key member states, led by the United States. Clearly, what drugs were listed or not listed had signiﬁcant ﬁnancial implications for manufacturers. The industry particularly objected to the exclusion of some of their most lucrative drugs from the list.47 The pharmaceutical industry disputed the economic justiﬁcation for the Model List, and argued that it should only be applied to the public sector of developing countries. It argued that application to the private sector and in high-income countries would result in sub-optimal medical care.48 With 11 of the world’s 18 largest pharmaceutical companies at the time based in the United States, the industry’s position was strongly supported by the US government.49 To put pressure on

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the organization, the US government successfully pushed for the WHO’s regular budget to be frozen in real terms in 1982. In 1985, the United States announced it would pay only one-ﬁfth of its assessed contributions to the UN, as a whole, and withhold its entire contribution to the WHO in protest against the APED. Despite these actions, the WHO has continued to revise the Model List every two years. The importance of rational prescribing to preventing drug resistance, a growing problem for antibiotics as well as drugs for malaria, tuberculosis, HIV/AIDS and other major diseases, demonstrated that the relevance of essential medicines was not limited to the developing world. Similarly, debates about rising health care spending in high-income countries also pointed to the need for costeﬀectiveness and generic substitution in the use of medicines. Today, four out of ﬁve countries have adopted national lists, accompanied in many cases by therapeutic manuals and formularies, information on generic substitution, and a global monitoring network for adverse drug reactions. While the concept of essential medicines has become ﬁrmly embedded in international and national health policy, and has become widely accepted as a key principle in the human rights approach to health, access to medicines in the developing world remains a major challenge. Since the mid-1990s, attention has shifted to two issues. The ﬁrst is the availability of essential medicines to meet health conditions faced by LMICs. In 1990 the Commission on Health Research for Development, followed by a second report in 1996 by the WHO Ad Hoc Committee on Health Research, reported that there was a major disequilibrium in the small proportion (10 percent) of funds spent annually on health research to address the health problems faced by the majority (90 percent) of the world’s population. This so-called “10/90 gap” means that many major conditions in the developing world receive little attention from pharmaceutical companies because they promise limited ﬁnancial return for investment in research and development (R&D). To help correct this gap, the Global Forum for Health Research, an independent international foundation, was established in 1998 to work towards shifting health research priorities. In 2003, seven organizations—the Oswaldo Cruz Foundation (Brazil), Indian Council for Medical Research, Kenya Medical Research Institute, Malaysia Ministry of Health, Pasteur Institute (France), Médecins sans Frontières (MSF) and, as a permanent observer, UNDP/World Bank/WHO Special Programme for Research and TDR, formed the Drugs for Neglected Diseases Initiative (DNDI). The initiative works to develop drugs on a not-forproﬁt basis, focusing initially on three neglected diseases (i.e. sleeping

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sickness, Chagas disease, leishmaniasis) not covered by other global health initiatives. As discussed in Chapter 5, other global public-private partnerships have been formed to support the development of medicines for speciﬁc diseases. The second problem faced by advocates of access to essential medicines has been the eﬀect of intellectual property rights on drug pricing. Campaigning by the governments of many LMICs, alongside CSOs, has centered on the potential for trade agreements, notably the Agreement on TRIPS, to hinder the availability of aﬀordable medicines. In 2001 the Declaration on the TRIPS Agreement and Public Health (known as the Doha Declaration), aﬃrmed the right of member states of the World Trade Organization (WTO) to interpret and implement TRIPS in a manner supporting the protection of public health and, in particular, access to medicines. While it was initially well received, consternation soon arose over interpretation of a speciﬁc paragraph of the Doha Declaration on compulsory licensing. After two years of further deliberation, the WTO Decision on the Interpretation of Paragraph 6 was announced in 2003, specifying when countries can import drugs produced elsewhere under compulsory licensing. The WTO describes the Paragraph 6 decision as removing the “ﬁnal patent obstacle to cheap drug imports.”50 While the Doha Declaration and Paragraph 6 decision aﬃrm important principles under the TRIPS agreement, regarding the protection of public health within international trade law, one-third of the world’s population still lacks access to essential medicines, a ﬁgure rising to over 50 percent in Asia and Africa. The main problems have been lack of progress in implementing TRIPS ﬂexibilities, amid stark inequalities in health resources and the world trading system as a whole, and the spread of so-called “TRIPS-plus” or “WTO-plus” measures under bilateral and regional trade agreements which are more restrictive of public health protections. As described in Chapter 5, these two sources of concern led the WHO to seek closer engagement with the trade policy community. Alongside the problems of neglected diseases and IPRs in restricting access to essential medicines, the WHO continues to the present day to face opposition to its Model List. In 2001, the organization published a proposal for an evidence-based prequaliﬁcation system that would permit pre-screening of the most urgently needed medicines at the international level, thus facilitating their use in countries without a fully functioning national agency for approving medicines (Box 4.4). The approval of ﬁxed-dose combination therapies for HIV/AIDS, including generic medicines, was given particular priority. The US

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Department of Health and Human Services, however, rejected the proposal, echoing industry claims that the approval process was insufﬁciently rigorous.51 As well as not permitting the US Food and Drug Administration to participate in the prequaliﬁcation program, the Bush Administration funded the PEPFAR instead of the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, in part because of the latter’s use of generic medicines, but also because of the administration’s preference for unilateral rather than multilateral engagement. In 2005, revision of the Model List was again delayed because of the Bush Administration’s objection to the inclusion of two drugs (mifepristone and misoprostol) used, inter alia, for medical abortions.52 Amid continued pressure, in 2002 the WHA adopted an evidence-based approach to essential medicines and the WHO Expert Committee on the Selection and use of Essential Medicines continues to be guided by these metrics.53

Box 4.4

The WHO Prequaliﬁcation Project

The Prequaliﬁcation Project, set up in 2001, is a service provided by WHO to facilitate access to medicines that meet uniﬁed standards of quality, safety and efﬁcacy for HIV/AIDS, malaria and tuberculosis. Any manufacturer wishing their medicines to be included in the prequaliﬁed products list is invited to apply. Each manufacturer must present extensive information on the product (or products) submitted to allow qualiﬁed assessment teams to evaluate its quality, safety and efﬁcacy. The manufacturer must also open its manufacturing sites to an inspection team which assesses working procedures for compliance with WHO Good Manufacturing Practices (GMP). Medicines which have been found to meet the required standards so far are from both brand name (42 medicines) and generic (61 medicines) manufacturers. These include 62 antiretrovirals and 33 medicines for HIV/AIDS-related diseases; two antimalarials and six drugs for the treatment of tuberculosis. Medicines containing one active ingredient and those combining several active ingredients in one pill, usually called ﬁxed-dose combination drugs, have been prequaliﬁed. In soliciting applications from companies, WHO does not question whether the products presented are patented or generic, since

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patent laws vary according to different national legal systems. It sufﬁces that a company is duly authorized for pharmaceutical manufacture in its own country and that the ﬁnal product meets stringent standards of quality, efﬁcacy and safety. Source: WHO (2004), “The WHO prequaliﬁcation project,” Fact Sheet No. 278, Geneva, www.who.int/mediacentre/factsheets/fs278/en/print.html.

Framework Convention on Tobacco Control Tobacco use remains the leading cause of preventable death in the world. With 4.9 million tobacco-related deaths per year, no other consumer product is as dangerous or kills as many people. Until the mid1990s, WHO’s tobacco control program comprised relatively few staﬀ, with limited resources, reﬂecting the low priority given to it by successive directors-general. The idea for an international instrument for tobacco control was initiated by the WHA in May 1995, and the following year Resolution WHA49.17 was adopted, requesting the DirectorGeneral to initiate the development of a Framework Convention on Tobacco Control (FCTC). It was not until 1999, a year after DirectorGeneral Brundtland identiﬁed global tobacco control as one of her two cabinet priorities (along with malaria), that concerted work on the FCTC commenced. Preparations of draft elements of the ﬁrst international health treaty were prepared by a Technical Working Group which met between October 1999 and May 2000. In October 2000, the WHO held public hearings that permitted interested parties within the public health community, tobacco industry and farmers’ groups to submit evidence for consideration during the negotiation process. This was followed by the opening of negotiations by the Intergovernmental Negotiating Body (INB) chaired by Ambassador Celso Amorim of Brazil. A chair’s text of the FCTC was prepared and then released in January 2001 as the basis for further negotiation by six further INB sessions held from 2001 to 2003. Regional inter-sessional consultations were also held during this period to support preparations for negotiation by member states. The process of negotiating the FCTC, formally adopted by the WHA on 21 May 2003, is widely recognized by the public health community as a major achievement. Foremost was the WHO’s direct confrontation with the tobacco industry, which mobilized substantial resources to covertly undermine the organization as part of an international strategy.54

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With ﬁrm support from Brundtland, the staﬀ of the WHO’s Tobacco Free Initiative countered industry eﬀorts by building its own alliances with other UN bodies, notably the World Bank, public health advocates and, more broadly, CSOs. The WHO’s close collaboration with CSOs, both during negotiation of the FCTC and in its subsequent implementation, has been a notable departure from the organization’s traditional focus on ministries of health. Prior to negotiations, oﬃcial recognition of selected CSOs was “fast tracked” to enable improved communication among groups already engaged in work around the FCTC process. The need for a more systematic outreach to NGOs, not yet engaged in the process, particularly in developing countries, resulted in the formation by CSOs of the Framework Convention Alliance (FCA). The FCA grew into 300 organizations representing over 100 countries which could both beneﬁt from, and contribute to, the creation of an eﬀective FCTC. The alliance has been especially important for leveraging support for the FCTC in the developing world, where tobacco control has been a relatively recent issue for the public health community.55 As well as serving as a successful example of WHO leadership on a major public health issue, the FCTC encompassed recognition of the need to address the broad determinants of health. Along with familiar health promotion measures to tackle tobacco consumption, the negotiations addressed such issues as the economic impact of global tobacco control on farmers, tobacco taxation, links between smoking and poverty, illicit trade in tobacco, and the regulation of corporate misbehavior. This attention to the structural aspects of the global pandemic led to an emphasis on approaches that involve a broad range of stakeholders and policy communities outside of the health sector. As of September 2007, 168 countries have signed the FCTC and 151 countries have ratiﬁed as full parties. In February 2006, a Conference of the Parties to the FCTC met to discuss how implementation of the treaty should be taken forward, including the creation of a permanent secretariat. Meanwhile, the Tobacco Free Initiative has acted as an Interim Secretariat, including preparing for the negotiation of additional protocols.

WHO Commission on the Social Determinants of Health Perhaps the most substantial analytical eﬀort to date by the WHO to address the broad determinants of health has been the Commission on the Social Determinants of Health (CSDH). The Commission was launched by Director General Jong-wook Lee in March 2005 and will complete its initial work in October 2008. Its stated purpose is to support

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member states and global health partners to address the social factors contributing to ill-health and inequalities.56 The main goals of the Commission are: To support policy changes in countries by promoting models and practices that eﬀectively address the social determinants of health. To support countries in placing health as a shared goal to which many government departments and sectors of society contribute. To help build a sustainable global movement for action on health equity and social determinants, linking governments, international organizations, research institutions, civil society and communities.57 These are to be achieved by drawing attention to the social determinants of health that are known to be among the worst causes of poor health and inequalities within and between countries. The determinants include unemployment, unsafe workplaces, urban slums, globalization and lack of access to health systems. The CSDH’s secretariat is based at the WHO’s Department of Equity, Poverty and Social Determinants of Health and at University College London in the United Kingdom. The Commission is chaired by Michael Marmot, given his seminal work on health inequalities and the social determinants of health.58 The four remaining commissioners are Frances Baum, Australian professor of public health and senior member of the People’s Health Assembly, former Canadian Minister of Health Monique Bégin, European Parliamentary member Giovanni Berlinguer, and Mirai Chatterjee, coordinator of a major trade union for self-employed women in India. The creation of the Commission can be seen as another attempt by the WHO to rebalance attention to the social factors that inﬂuence health. As Orielle Solar and Alec Irwin write, [S]ince World War II, global public health has oscillated between a social vision of health and a more individualistic, technological and medicalised model. Action on SDH was central to comprehensive primary health care as promulgated at the 1978 Alma Ata conference and championed by the movement for “Health for All by the Year 2000.” Subsequently, commitment to addressing SDH declined under the impact of restrictive interpretations of “selective primary health care” and the pressure of neo-liberal economic and health policies.59 This swing back towards social medicine was prompted by widespread changes to societies worldwide resulting from rapid globalization and, in particular, the relative neglect of their social and environmental

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impacts. The same reason led to the establishment in 2002 by the ILO of the World Commission on the Social Dimension of Globalization. This commission was an independent body of prominent individuals from government, business and civil society which sought to “move the debate from confrontation to dialogue, and thereby set the stage for action. How can the beneﬁts of globalization reach more people?”60 In the WHO, the previous work of the Commission on Macroeconomics and Health (see Chapter 5), under Jeﬀrey Sachs, had pushed health higher on political agendas by demonstrating that health is critical to economic development. It is hoped that the CSDH will achieve the same in arguing for the promotion of health equity. Prior to the publication of the CSDH’s ﬁnal report in 2008, concerns about its ability to inﬂuence the policy agenda were raised. The unexpected death of Lee in 2006 brought fears that the Commission’s work might fall by the wayside under a new Director-General with a strong background in infectious disease control. In an open letter to the incumbent, Margaret Chan, the People’s Health Movement encouraged continued commitment to the “work of the Commission of the Social Determinants of Health in narrowing health inequalities through their recommendations for action on the social determinants.”61 The scope of the CSDH’s work has also raised concerns. For example, Debabar Banerji argues that the body faced an impossibly broad task, in seeking to ambitiously draw lessons for such a diverse range of countries and 13 policy areas. She also criticized its failure to draw on available evidence, choosing instead to devote considerable time and resources to working with “country partners” to collate new information.62 Perhaps most challengingly, the Commission has sought to reconcile fundamentally diﬀerent political perspectives on the nature of the global political economy and, in turn, the causal factors leading to health inequalities. While Marmot saw the CSDH as “complementing” the CMH,63 this alarmed those who sought a more radical transformation of the world order.

Conclusion While the WHO has been historically dominated by the biomedical model of health, there have been periodic attempts by the organization over the past six decades to tackle the broad determinants of health. These attempts were most notable from the 1970s under Director-General Mahler. After two decades of keeping its institutional head below the parapet, the WHO allied itself with public health advocates who, armed with the Basic Needs Approach, sought to challenge some of the most

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powerful vested interests inﬂuencing health and disease within a fundamental rethinking of health development. While Health for All and the PHC movement were, in many ways, a reﬂection of the greater assertiveness of the developing world in the UN as a whole, they were also based on recognition of the inadequacy of existing approaches to address the substantial health needs of the majority of the world’s population. Mahler’s support of the International Code on the Marketing of Breast Milk Substitutes, Model List of Essential Drugs and PHC movement, followed by Brundtland’s championing of the FCTC, are heralded by advocates of social medicine as examples of what the WHO needs to do more of. However, these initiatives have also come at considerable cost. The initiatives have elicited sustained criticism from its most powerful member state, the United States, which has publicly expressed its disapproval by occasionally withholding its regular budget contributions. For an organization chronically short of resources, such actions have been unhelpful at best. More harmful, however, has been the US government’s sustained support for a freeze on the WHO’s regular budget, ﬁrst in real terms, and then in 1993, in absolute terms (zero nominal growth). On this policy, the United States has been joined by other major donor countries. Most damaging of all, however, has been the capacity of major donor countries to shift the locus of international health policy from the WHO to other global health initiatives. Undoubtedly, this has been prompted in large part by the shortcomings of the WHO itself and its own failure to regain the conﬁdence of key member states. At the same time, it is also clear that there has been a deliberate eﬀort by certain vested interests to undermine the organization. Facing a direct threat to their capacity to pursue markets across the world, and even international regulation, the food, pharmaceutical and tobacco industries have participated in a sustained eﬀort to keep the WHO focused on biomedicine. In this context, the likelihood that the WHO Commission on the Social Determinants of Health will pose a radical threat to the existing world order is doubtful. Indeed, the WHO remains caught between those looking to the organization to become more politically active, taking on the powerful forces that structure the global political economy within which health is broadly determined, and those who argue for a restricted, largely technocratic role for the WHO, many of whom do so to protect their own vested interests. The tensions between vertical and horizontal approaches to health go far beyond technical considerations, therefore, to subsume more fundamental philosophical and ideological debates. As will be shown in Chapter 5, these tensions have continued to deﬁne the health ﬁeld as new global health initiatives have come on the stage.

5

From international to global health

Since the 1990s, international health cooperation has perhaps faced the greatest pressures to change since the end of the Second World War. Foremost has been the acceleration of globalization, which has created diverse and complex impacts on societies across the world. Populations able to adapt to these changes have been able to reap the beneﬁts of globalization; large numbers of others have found themselves unable to do so and are even bearing a disproportionate burden of its costs. For the health sector, globalization is also inﬂuencing the determinants of health and health outcomes in ways that are only beginning to be understood. The same pattern of “winners” and “losers” has emerged, with evidence of widening health inequalities within and across countries. As globalization continues apace, public health institutions operating at all levels of governance must now adapt and respond. As a result, the WHO’s place in international health cooperation has never come under more scrutiny. Alongside renewed questions about its internal workings as the UN specialized agency for health, comparisons with other organizations have become more intense, given the creation of new global health initiatives. The WHO’s operating environment, in other words, has become far more crowded and competitive. This ﬁnal chapter describes pressures on the WHO to shift from international to global health cooperation, the latter distinguished by the need to engage with a greater range of interests, as well as with forces that ﬂow across countries as a result of globalization. As well as satisfying its traditional constituencies, namely its member states, the WHO has been required to reach out to new stakeholders, develop new forms of health governance, and address even broader determinants of health. In many ways, there have been new opportunities for the WHO to assert its leadership and re-establish itself as the world’s health organization. Public health has never been higher on the policy agendas of world leaders, yielding unprecedented resources for global health

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cooperation. Yet correspondingly, “global health” has also become a highly contested ﬁeld, as new initiatives have fought for power and inﬂuence. A battle to deﬁne the meaning of “global health” has ensued, challenging WHO to revisit long-standing issues about its mandate, its functions and, most signiﬁcantly, its underlying value systems.

The governance of the WHO under scrutiny: reform and more reform As discussed in previous chapters, questions about the appropriate role of the WHO have been regularly raised throughout the organization’s 60-year history. In 1951, Director-General Brock Chisholm described the WHO as having the “experience and techniques enabling it to give to each country the kinds of assistance needed to raise signiﬁcantly its health level.”1 A year later, Charles Ascher wrote of a WHO which “should be concerned with applying science not doing science” in response to opposition by some member states to the “project” approach to health.2 Jason Finkle and Barbara Crane welcomed the organization’s recognition of family planning as within its sphere of inﬂuence, but lamented the biomedical culture which inhibited a stronger commitment to fertility control from the mid-1960s.3 Javed Siddiqi describes the shift from the vertical Malaria Eradication Programme to the more horizontal approaches from the late 1970s as an indication of “WHO’s desire to learn from, and improve upon, past mistakes.”4 As described in Chapter 4, however, others saw the WHO’s engagement with the broad determinants of health as an inappropriate politicization of its role. Each decade has brought new questions, iterated by succeeding generations of constituents seeking to interpret the WHO’s mandate and functions. Nonetheless, since the early 1990s, the WHO has faced a particularly contentious time as a result of sustained concerns about its role amid a rapidly changing operating environment. In 1994, the British Medical Journal (BMJ) published a series of scathing articles about “an organization whose system conspires against the best eﬀorts of its staﬀ.”5 The author, medical journalist Fiona Godlee, wrote that “WHO has an image problem. People know that it exists. … but few have a clear idea of what it does.” The wide-ranging series pointed to the WHO’s leadership as a key problem. While Mahler was described as a “visionary,” his successor, Nakajima, was criticized as “a poor communicator,” “autocratic” in style, and prone to inappropriate patronage appointments. Godlee saw the WHO as failing to rise to new challenges:

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WHO has failed to come up with convincing new initiatives to confront major health threats such as population growth and tobacco. It is in retreat, stuck despite its multi-sectoral rhetoric in the outdated medical model of health, and badly in need of leadership if it is to evolve to meet the health challenges of the next century.6 There were mixed responses to the BMJ series. Some praised Godlee for articulating growing concerns about the organization, notably among donor governments. Others, including those loyal to the organization if not to its current leader, criticized the author for her indiscriminate condemnation of the organization, which inﬂicted collateral damage on more successful programs. There was some dispute about the factual accuracy of some of the claims put forth by the series, as well as concerns that it played into the hands of certain interest groups who would beneﬁt from the WHO being reduced to an ineﬀective body. Above all, the series marked the ﬁrst time such a frank assessment of the WHO had been published. The Godlee series was correct in reﬂecting a clear disenchantment among donor countries of the WHO’s internal dysfunction. As described in Chapter 2, the main means of leverage used by donors was ﬁnancial, ﬁrst to freeze the WHO’s regular budget in real terms from the early 1980s, a policy also imposed on other UN organizations, and then in 1993 to freeze the regular budget in nominal terms. At the same time, the provision of extrabudgetary funds (EBFs) was increased to support selected programs deemed “value for money” by donors. In 1971, EBFs represented 25 percent of the total budget. By the mid1990s this proportion had increased to 54 percent.7 Financing the organization in this way allowed donors to circumvent the WHO’s weak leadership and unevenly performing Secretariat. While ﬁnancial resources have regularly been a constraint on WHO activities in the past, the freeze on the regular budget led the organization to operate for the ﬁrst time at a considerable deﬁcit ($51 million).8 As described in Chapter 2, the growing imbalance of RBFs and EBFs led three donor governments (Australia, Norway and the United Kingdom) to commission a major study of the funding of the WHO in 1994. The informal grouping, known within diplomatic circles as “likeminded countries,” was distinct from the United States, for example, in sharing a commitment to strengthening multilateralism and the UN. Thus, while they shared concerns with other major donors about the WHO’s internal dysfunction, they remained committed to reforming rather than starving the organization of resources. The study, carried out independently by the London School of Hygiene & Tropical Medicine

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and the Centre for Partnership in Development in Norway, carefully negotiated “support and cooperation” from the WHO. Nakajima directed senior staﬀ to participate in donor-led meetings on the study, and to collaborate with the study group in providing needed information. The objective of the study, the most detailed analysis of WHO ﬁnances to date, was to assess the eﬀectiveness and value-for-money of WHO’s extra-budgetary funded programme activities at global and country levels. It shall pay particular attention to the appropriateness of WHO’s extrabudgetary funded activities as a channel of international cooperation for health development aimed at bringing about sustained improvements in health status in developing countries.9 The resultant report, known as Oslo I, concluded that donor preferences, expressed through earmarking of EBFs, were unduly inﬂuencing the WHO’s policy agenda. However, the report found that this inﬂuence was possible because of the WHO’s own lack of strategic vision. It recommended that there be a “re-examination of the overall programme structure” to create more coherence and strategic direction. The WHO needed to show stronger leadership in setting the global health policy agenda and donor governments needed, in turn, to recognize that leadership through the provision of funding without earmarking. The study received a largely positive response from the WHO and donor governments, the latter continuing behind-the-scenes meetings and discussions on the organization’s reform. The most signiﬁcant was a 1996 retreat to discuss the current state and future role of international health institutions. Initiated by Harvard University, the meeting was supported by the Rockefeller Foundation and held at the Foundation’s estate in Pocantico Hills, New York. The meeting was attended by key individuals, including Halfdan Mahler, Richard Horton (editor of The Lancet), Julio Frenk (Mexican Health Foundation), Adetokunbo Lucas (former head of the UNICEF/UNDP/World Bank/ WHO Special Programme for Research and Training in Tropical Diseases), Derek Yach (WHO), Dean Jamison (senior economist at the World Bank), and leading scholars on WHO reform such as Gill Walt10 (also a co-author of Oslo I), all of whom would contribute to informing or implementing ensuing reforms. The discussion focused on the WHO’s leadership and the need for an individual of prominent stature to “rescue” the organization. In 1997, an informal regional follow-up meeting on the same subject was held at the National Institute of Public Health, Cuernavaca, Mexico, on 3–4 February 1997.11

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A ﬂurry of analyses on WHO reform appeared during this time, including initiatives by the governments of Sweden, Australia and the Dag Hammarskjold Foundation.12 The most substantial was a study, initiated in 1997 by an expanded group of “like-minded countries” (joined by Canada and Sweden), to assess WHO activities at country level. Once again, collaboration with the WHO’s senior management was carefully negotiated and maintained. The study’s report, known as Oslo II, produced detailed data on the speciﬁc activities of 12 WHO country oﬃces, and spurred an internal review of how resources were allocated across the three levels of the organization and its six regions (see Chapter 2). As well as producing important reviews of WHO ﬁnances and country-level activities, Oslo I and II grappled with broader questions concerning the WHO’s mandate and functions. Traditionally, functions have been categorized as either normative or technical. Normative activities are seen as carried out at the global level, involving knowledge-based activities such as the setting of standards and guidelines. In contrast, technical activities, involving the application of knowledge, are more operational and take place largely at the country level. Many argue, to the present day, that the WHO should focus on normative activities and leave implementation to organizations such as UNICEF.13 Oslo II challenged the appropriateness of separating functions in this way, arguing that normative activities were often derived from activities carried out at the country level. While the distinction between normative and technical activities remains in widespread use, the study fed into wider debates about how the WHO’s broad mandate, as set out in its Constitution, might be interpreted into “core functions.”14 In 1998 eﬀorts to initiate an “Oslo III” to analyze WHO activities at the regional level, by the Japanese Ministry of Health, coincided with the election, on a manifesto of organizational reform, of a new Director-General, Gro Harlem Brundtland (Box 5.1). Donor countries decided instead to see what changes the new administration would introduce.

Box 5.1

Gro Harlem Brundtland

Born in Oslo, Norway on 6 April 1939, Gro Harlem Brundtland earned her medical degree from the University of Oslo in 1963 and then Master of Public Health from Harvard University in 1965. From 1966 to 1974, she worked as a physician at the Directorate of

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Health and public school health service. Brundtland served as Norwegian Minister of Environmental Affairs between 1974 and 1979, and became Norway’s ﬁrst female Prime Minister in 1981, remaining in the post until 1996. During this period, she also enjoyed a prominent international career, notably serving as Chair of the World Commission on Environment and Development (WCDE) known as the Brundtland Commission, which developed the concept of sustainable development and provided political support for the Earth Summit in 1992. Brundtland’s election as WHO Director-General in 1998 was widely welcomed, with high hopes for the organization’s renewal. Many saw her as cut from the same cloth as Mahler—a Scandinavian with deep moral convictions and a capacity to bring together broad constituencies. Importantly, as well as medical training, she brought political skills and experience to the post: “There is a very close connection between being a doctor and a politician. The doctor tries to prevent illness, then tries to treat it if it comes. It’s exactly the same as what you try to do as a politician, but with regard to society.” Her broad approach to public health led her to initiate a range of new initiatives, such as the Commission on Macroeconomics and Health, as well as address long-standing yet neglected issues such as tobacco control and malaria control. Brundtland’s decision not to seek re-election in 2003 came as a surprise, and with some degree of disappointment even from her detractors. While her extensive reform program brought mixed results, most agreed that reform had been much needed. Since leaving the WHO, she has continued to pursue a high-proﬁle international role, for example, serving as a member of the Panel of Eminent Persons who reviewed the work of the UN Conference on Trade and Development, and a group convened in 2007 by Nelson Mandela, Desmond Tutu and Graca Machel (widow of the late Mozambican president Samora Machel and now wife of Mandela), known as “The Elders”, selected world leaders who contribute their wisdom, independent leadership and integrity to tackle some of the world’s most difﬁcult problems. Sources: Nancy Gibbs, “Norway’s Radical Daughter,” Time, 25 September 1989; and Chris McGreal, “Mandela’s Elders to Tackle Global Crises,” Guardian, 19 July 2007.

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The election of Brundtland thus came with high hopes that new leadership would re-establish the WHO’s standing. Expectations ran especially high that the former Norwegian Prime Minister would use her previous experience as a politician and diplomat, including her role in chairing the WCED, to do the same for health. The WHO urgently needed an injection of credibility if it was to regain its international standing. As Nils Dallaire noted: “Those of us working in public health at the time used to say WHO was where good ideas go to die.”15 Brundtland was expected to reverse this perception. In many ways, Brundtland did not disappoint. An immediate and wideranging program of reform was initiated at Geneva headquarters to create “a ﬂatter structure, better communication, more transparency.”16 One of the most visible changes was the rationalization of the multitude of WHO programs into nine “clusters.” One common complaint about the WHO was the uncontrolled proliferation of programs, from adolescent health to zoonosis, in accordance with the organization’s broad deﬁnition of health. The problem was that if everything was a priority, then nothing was a priority. Brundtland sought to prune judiciously, as well as group the remaining programs into more manageable sections. An Executive Director was appointed to each cluster, and together they formed a ten-member government-style “cabinet.” This also addressed another criticism, that the WHO had become “top heavy.” Under Nakajima, there had been an increase in director-level appointments, from 88 in 1998 to 114 in 1994. Posts above director also increased from 7 to 13 over the same period.17 Brundtland immediately reduced this to 9. In terms of individuals, several staﬀ who had been marginalized under the previous administration were promoted to prominent positions. This included Yach, who was appointed to lead the cabinet project, the Tobacco Free Initiative (TFI), and later to be Executive Director of Non-communicable Diseases. Former head of health of the UK Department for International Development, David Nabarro, was brought in as senior advisor to the Director-General (he would later be named Senior UN System Coordinator for Avian and Human Inﬂuenza). Other senior staﬀ remained in post to provide administrative continuity, notably Denis Aitken and Ann Kern (who also contributed to Oslo I). More controversial was Brundtland’s decision to bring in prominent individuals who were perceived to be associated to varying degrees with the World Bank, such as Christopher Murray, Julio Frenk and Alan Lopez. The détente between the WHO and the World Bank is discussed further below. Along with this changing of the guard, Brundtland sought to introduce a corporate culture to the organization in the hope of making it

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less bureaucratic and more eﬃcient. Fixed-term appointments, performance-monitoring processes and a results-based management framework were introduced to create a leaner and meaner work force. Terms such as “synergies” and “coherence” began to be used throughout the organization, to encourage collaboration across health areas where silos of activity had developed. Andresen writes that “overall WHO stands forth today as a more vital and visible organization than it did in 1998, and leadership has played an important part in this development.”18 The extent to which Brundtland was able to fundamentally reform the WHO remains subject to debate. Faced with criticism that it must “change or die,”19 the organization urgently needed to ﬁnd new ways of working. A rationalized structure and strategic programming, after the evolutionary growth of the organization’s work program over many decades, was essential in the face of greater resource limitations and pressures to set clearer priorities. Yet the time-frame for reform began to extend much longer than anticipated, spanning Brundtland’s entire term in oﬃce, and the problems were more intransigent than ﬁrst realized. Internally, enthusiasm for reform began to wear thin. Staﬀ morale began to drop as thoughts turned to job insecurity (in large part a reﬂection of the increase in EBFs received for short-term projects). As Leonard Lerer and Richard Matzopolous write, Brundtland’s eﬀorts to introduce a global business model to the WHO, through “harsh reengineering and the search for high-proﬁle ‘success stories’” were misjudged. Ironically, as global business moved towards collaboration, empowerment, and knowledge sharing, the WHO created “the worst of both worlds.”20 Brundtland’s relationship with key donor governments was initially positive, as reﬂected in the steady increase in EBFs provided to the organization (see Table 2.2). Some EBFs, such as from the UK government, were not earmarked beyond the cluster level, a show of conﬁdence in the WHO’s own ability to allocate resources strategically. Yet limited funding to carry out its work remained an ongoing problem. This fuelled competition among clusters to attract scarce resources. The WHA continued to impose a policy of zero growth in nominal terms to the regular budget, keeping the WHO vulnerable to the approbation of major donors. As Yamey writes, “if we, the international health community, want WHO to carry out the tasks for which it has the comparative advantage, we need to provide it with adequate resources for these vital activities.”21 The dire lack of RBFs in 2006 led to an agreement by donors to permit the WHO to use EBFs to cover some core running costs.22 Perhaps Brundtland’s most important achievement was her successful advocacy of global health on the world stage. Drawing on her

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extensive political experience, the Director-General embarked on an exhausting campaign to argue for high-level support for key health issues from world leaders at major international meetings. For this purpose, health was framed strategically in terms of other policy goals, such as development, economic growth, poverty reduction, and national security (Box 5.2). This would be Brundtland’s most signiﬁcant legacy, contributing to the reinvigoration of attention by major donor governments to health issues. For example, three out of eight Millennium Development Goals (MDGs) agreed in 2000, 8 of the 16 targets, and 18 of the 48 indicators, relate directly to health.

Box 5.2 Brundtland puts health on the world stage I see that so very clearly from the position of world health, where we can list so many concrete interventions which would make a huge difference for the lives and perspectives of billions—ranging from immunizing half the children of Africa who don’t get the vaccines—to providing bed nets to the millions of children who are living in acute danger from the malaria mosquito. If we do this—poverty will go down. Societies will develop. And ultimately new markets will open. Speech to World Business Council for Sustainable Development, 1999.23

That poverty causes ill health is well known. But good health can fuel the engine of development and add signiﬁcant momentum to the forces of economic development and poverty reduction. Speech to the Development Assistance Committee of the OECD, November 2000.24

… health must be seen as a central factor not only in social development, but also in countries’ ability to compete on the global economic stage and achieve sustainable economic progress. … enlightened self interest compels both industrialized country governments and private corporations to do what it takes to drastically reduce the current burden of disease in the developing world. To do so will be good for economic growth, be good for health and be good for the environment. Speech to the Washington International Business Council and Executive Council on Diplomacy, April 2001.25

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Diplomats from wealthy nations are having to keep pace with a changing agenda, and move into uncharted waters. They no longer argue that it is “outside their national interest” to be involved in international health issues. They are showing new leadership, and drawing on their reserves of wisdom, to grasp new opportunities. They focus on results as well as process, ﬁghting to avoid supporting initiatives that are destined to wither and be ineffectual. Global health is now ﬁrmly embedded in their objectives. Speech to Health as Foreign Policy conference, April 2002.26

Eﬀorts to reassert the WHO’s lead role in international health cooperation from the late 1990s were made even more necessary by the ascendance of rival institutional actors. As well as familiar competition with other UN organizations, such as UNICEF for inﬂuence and resources, the WHO faced new competition from the World Bank, CSOs and a proliferation of global public-private partnerships concerned with health. While many European donor agencies were keen to support the WHO, others wanted to encourage a form of market competition among various global health initiatives, believing that this would lead individual organizations to reﬂect on what they did best. At the Executive Board meeting of 2000, Brundtland described the challenge in this way: What is our comparative advantage? Given our mandate and our human and ﬁnancial resources, what are the functions that WHO is best placed to carry out more eﬀectively than others? How can we shift the balance of our work to focus even more forcefully in areas where our comparative advantage really lies? And most importantly, how can we increase the impact of our contribution by engaging a variety of partners who can supplement and complement that contribution? The same goal, of identifying the WHO’s “added value,” was advocated by the UK Department for International Development.27 As the above reforms progressed, there was growing realization that attention to headquarters was only a ﬁrst step. Long-standing and deep-rooted problems (such as nepotism, poor performance and bureaucratic indolence) at the regional and country levels also required

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concerted attention.28 Brundtland then made the surprise decision not to continue in oﬃce for a second term. The pressures of tackling the complex reform of such a large organization, while ﬂying the ﬂag for health globally, required enormous professional and personal commitment. Some saw her departure, along with a number of her senior appointees, as leaving the WHO with uncertain leadership once again. Others welcomed a hiatus from the ongoing reform program. The election of a compromise candidate in May 2003, Lee Jong-wook of South Korea, reﬂected the divided opinions on Brundtland’s tenure. Having been sidelined by the Brundtland administration to a relatively obscure position, Lee suddenly found himself at the helm. He made several changes to senior positions, and a number of individuals closely identiﬁed with Brundtland, such as Yach, eventually left the organization. Lee’s relatively brief period in oﬃce, cut short by his unexpected death in 2006, went some way to allaying concerns about the ability of the WHO to reassert itself among growing numbers of global health initiatives. The outbreak of SARS in 2002–3 required Lee to step into his new post at a critical time. Immediately prior to his assuming oﬃce, Brundtland’s assertive stance, notably in pressing China to cooperate and issuing travel advisories, had put the organization at the center of the global response. The WHO’s worldwide mobilization of scientists to identify and genetically sequence the infectious agent was especially impressive. By July 2003, the outbreak was declared over, but Lee managed to maintain the momentum gained from SARS to restart the process of revising the International Health Regulations, completed in 2005. Although an expert in infectious disease control, notably as former Director of the Stop TB department and head of the Global Programme on Vaccines and Immunization, Lee sought to demonstrate his support for a wider health agenda. The successful conclusion of the FCTC came as he was elected, among the most high-proﬁle products of Brundtland’s tenure. It was rumored that Yach was not permitted to attend the World Conference on Tobacco or Health in August 2003 because it would overshadow Lee’s presence. Nonetheless, it was an important early opportunity for the new Director-General to assert himself, a diﬃcult task in the wake of such a dynamic predecessor. Unlike Brundtland, Lee had extensive experience of the WHO at all three levels of the organization, with particular commitment to supporting member states. It was during his term that the WHO was faced with responding to avian inﬂuenza, the Asian tsunami and a devastating earthquake in Pakistan. To build the proﬁle of the WHO, Lee introduced “Goodwill Ambassadors,” reminiscent of UNICEF, to act as advocates of the WHO’s work.

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Lee also continued the reform program, with particular attention to creating more strategic and transparent administrative and budgetary procedures. However, internal labor relations continued to deteriorate under Lee. In November 2005 several hundred WHO staﬀ at headquarters staged a work stoppage in protest at the scheduled termination of 200–300 ﬁxed-term positions. Lee threatened to ﬁre those who took part, but did not back up the threat when the stoppage went ahead.29 In 2006 the public departure of Alison Katz, a long-serving social scientist in the AIDS program, was accompanied by an open letter to the newly elected Director-General Margaret Chan.30 This was perhaps the most overt demonstration of dissatisfaction by staﬀ after numerous changes in leadership and eight years of organizational reforms. The election of Chan as Director-General in October 2006 re-ignited debates surrounding the electoral process begun in 1993. The reelection of Nakajima had come amid rumors of rewards being oﬀered to member states in exchange for votes. Historically, elections have been a “closed shop,” with nominated candidates assessed by the Executive Board, which puts forth one individual to be formally elected by the WHA. The WHA is largely seen as a “rubber stamp,” with the real campaigning going on behind the scenes in the nomination and selection stages. While EB members are formally required to act independently of national aﬃliation, in practice member states jostle for their favor in exchange for votes. While the election of directorsgeneral and regional directors has long been recognized as highly political, the international health community pressed for greater scrutiny as part of a broader movement for improving the governance of international organizations. One leading advocate for electoral reform was the editor of The Lancet, Richard Horton, who pushed candidates to publish their manifestos in an eﬀort to improve transparency. CSOs also pushed for greater transparency. Candidates publicly stated their visions for the WHO’s future, and key questions were put to them to respond to. Based on an assessment of each candidate’s strengths and weaknesses, the inﬂuential medical journal even took the unprecedented step of naming its preferred candidate, Mexican Minister of Health Julio Frenk. However, Frenk became the subject of some controversy over his alleged granting of tax concessions to the tobacco industry in Mexico.31 He failed to make the ﬁrst shortlist, perhaps because of these allegations, but more likely because of perceptions that he was the favored candidate of the unpopular Bush Administration. Also inﬂuencing the process were vacancies at the same time for Director of the

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GFATM and head of Health, Population and Nutrition at the World Bank, as well as early discussion of candidates for the next UN Secretary General.32 Custom required that these posts be distributed equitably among major countries and regions. Overall, while the WHO elections still take place largely behind closed doors, pressure by the public health community conﬁrmed the intensely political nature of the process. While this was no surprise, by making the 2006 election the most open in WHO history, campaigners sought to improve the quality of the political process. After more than a decade of WHO internal reform, Chan assumed oﬃce in January 2007, aware of the desire among staﬀ for stability rather than further change. In her inaugural address to the Executive Board she stated, “I will continue ongoing reforms at WHO, but will not introduce changes that cause upheaval. Staﬀ and the programmes they implement need continuity. There will be some changes, but these will be gradual and carefully managed.”33 In October 2007, she announced changes to selected clusters “to bring a closer alignment around our work on health security [see below] and the environment, endemic communicable diseases, research and UN reform.” She announced relatively minor changes to her inherited “cabinet,” with key individuals under Lee remaining in post.34

The ascendance of economism: the World Bank in health development After decades of ﬁnancing major infrastructure projects in the developing world, the World Bank shifted greater attention to social sectors such as health and education. Under President Robert McNamara, the Bank began to lend for health development in the early 1980s, rapidly increasing it from the late 1980s to become the leading source of development ﬁnancing. During the same period, as described in Chapter 2, the WHO regular budget remained subject to a policy of zero real and nominal growth (see Figure 5.1).35 Bank expertise in health grew correspondingly, and by the mid-1990s it had arguably displaced the WHO as the leading institution in health development.36 As well as ﬁnancial clout, this shift in inﬂuence reﬂected the rise of economism in health policy, which rivaled, and to some degree, displaced biomedicine. The ascendance of neoliberalism from the 1980s led to the adoption of policies focused on reducing public spending and achieving greater eﬃciencies within the public sector. In the health sector, the expertise needed to formulate and implement such policies lay not within traditional public health, but in the rapidly emerging

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Figure 5.1 World Bank health lending versus WHO budget, 1984–1996. Source: Kent Buse and Catherine Gwin, “World Health: The World Bank and Global Cooperation in Health: the Case of Bangladesh,” Lancet 351(9103): 665–69 (28 February 1998).

ﬁeld of health economics. The World Bank’s technical expertise in economics, backed by development ﬁnancing, thus put it in a strong position to shape the wave of health sector reforms which swept around the world.37 The legacy of the Bank’s foray into the health sector remains highly controversial. There has been much criticism of the adverse impacts of SAPs on LMICs, notably policy conditionalities such as cost recovery and privatization. Notable was the allegiance of the Bank’s health policies to the so-called Washington Consensus. The seminal report of the Bank’s transfer of neo-liberal policy measures to the health sectors of the developing world was the World Development Report 1993, Investing in Health. For many, the report was anathema to basic values underpinning public health, such as equity and social justice, resulting in tensions between the WHO and the Bank: Despite progressive-sounding language about “empowerment” and “health for all,” this report is a masterpiece of disinformation. “Investing in Health” proposes a “three-pronged policy approach to health reform” which can “save millions of lives and billions of dollars.” At face value, each prong sounds reasonable, even moderately progressive. Underpinning this agenda, however, have been

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certain values, ethical goals and assumptions derived from a dominant neoliberal agenda.38 The détente between the WHO and the World Bank from the late 1990s stemmed from recognition by Brundtland of the clear inﬂuence of economism. Upon assuming oﬃce, she recruited Christopher Murray and Alan Lopez, who had led the Global Burden of Disease project, along with Frenk. She established a new unit, Evidence and Information for Policy, which built on the concept of disability-adjusted life years (DALYs). As part of the reform process, Brundtland sought to improve the economics-based evidence of the WHO’s work, and to use this evidence to set priorities. In addition, former head of population, health and nutrition at the World Bank, Richard Feachem (who later became the ﬁrst director of the GFATM) was appointed editor of the WHO’s ﬂagship journal, the Bulletin of the World Health Organization. As described by one leading academic, the WHO had become “a branch of Harvard and the World Bank.”39 Despite criticisms of the methodology behind the GBD project, the new WHO unit undertook an assessment of the performance of national health systems, ranking countries on a league table based on expenditure and health outcomes. It ranked the health systems of 191 countries by “healthy life expectancy” (HALE), deﬁned as the average number of years that a person can expect to live in “full health.” The results, published in the World Health Report 2000, Health systems, improving performance, met with a storm of criticism from both the political left and right. For the US government, whose health system was ranked lower than expected, given high health expenditure per capita, the report was accused of being incomplete, obsolete, and unjustiﬁed in its assumptions. For the political left, many felt uneasy at the apparent embrace by WHO leaders of discredited World Bank policies. Lister describes the report as a radical change in approach from the World Health Report 1995, Bridging the gaps,40 which identiﬁed poverty as the number one cause of ill-health. Drawing attention to widening inequalities between rich and poor, the 1995 report identiﬁed SAPs as contributing to ill-health. In contrast, the 2000 report was seen by some as undermining eﬀorts to improve health equity,41 linking ill-health to health spending rather than to poverty per se.42 As Navarro writes, The maximum expression of the ideological revolution taking place at the WHO is evident in the 2000 report Health Systems: Improving Performance, prepared under the direction of WHO oﬃcial Julio Frenk and WHO consultant Christopher Murray.

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From international to global health This report established the neoliberal narrative as oﬃcial WHO policy.43

Even the editor-in-chief of the report, World Bank economist Philip Musgrove, on loan to WHO, questioned in detail the methodology, consultative process and internal reasoning behind the report.44 Another example of the rise of economism in global health policy was the WHO Commission on Macroeconomics and Health (CMH), led by former Harvard economist Jeﬀrey Sachs. The purpose of the Commission was to provide evidence to further Brundtland’s goal of raising health on the political agendas of world leaders. As she stated to the Permanent Missions of the UN in Geneva in 1998, WHO has to be the vocal force to drive home the message that poverty remains the biggest source of ill health—and that ill health in turn breeds poverty. We need to present the evidence and develop the language to demonstrate that the right investments in health—to all—but especially to children and women—means investing in a strong economy … 45 The Commission’s report argued that good health was central to economic development, and economic development, in turn, could not be achieved within an environment of ill-health. Ill-health, in other words, was a barrier to development and needed to be addressed in poor countries as a core part of their development strategies.46 The Commission’s report, and its advocacy by Sachs, played an important role in increasing funding for global health. This included agreement of the Millennium Development Project for which Sachs was named director, and commitment by the Group of Eight countries to the creation of the GFATM. The WHO’s closer links with the World Bank were not universally dismissed within the public health community. For example, the World Bank played an important strategic role in supporting the FCTC by providing evidence challenging long-established economic rationales for protecting the tobacco industry.47 In the report, Curbing the Epidemic: Governments and the Economics of Tobacco Control, it was shown that the net costs to societies from tobacco use far outweighed beneﬁts from tax revenues and employment.48 This was a notable reversal of previous Bank policy which ﬁnanced tobacco farming as a development strategy. It is clear that diﬀerent schools of economism have emerged which, to varying degrees, challenge the neoliberal orthodoxy. For the WHO, the World Bank is now an established institution with interests

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in global health. Richard Horton describes it as “the leading global development institution for human health.”49 In more recent years, the World Bank has not been without its own problems in deﬁning its mandate. The publication of a new 10-year health strategy in 200750 has been accompanied by uncertainty over its future role, given the ascendance of new ﬁnancing sources (e.g. bilateral aid from China). For example, the Bank may draw on its lead expertise in health systems policy development, leaving the WHO to focus on technical aspects of health development.51

Partnerships as modus operandi: cooperation or co-option? The rise of “Third Way” politics, which seeks to ﬁnd a middle ground between traditional left- (interventionism) and right- (laissez faire market liberalism) wing politics, has informed WHO eﬀorts to form a broader range of partnerships. Recognizing the importance of building closer links with outside organizations, upon assuming oﬃce Brundtland formed the cluster on External Relations and Governing Bodies whose mission was to build partnerships and alliances with other key actors such as other UN agencies, NGOs and the private sector. It will organize the work of the governing bodies, strengthen WHO collaboration with all its Member States and help devise a broader strategy of reaching out to the outside world. A lot needs to be done in this area.52 She sought to professionalize its operation with the appointment of Ambassador Jonas Gahr Store as head of the Director-General’s Oﬃce. Upon taking up his post, Store stated, “The ﬁeld of health is new to me; but I trust the good technical people and just focus on the political process and diplomatic challenge of putting health on the political agenda.”53 A major focus of these eﬀorts has been greater engagement with the private sector. Following Brundtland’s call for “open and constructive relations with the private sector,”54 the private sector became more involved in a range of WHO initiatives.55 For example, the pharmaceutical industry was invited to contribute to the FCTC, notably in the development of nicotine replacement therapies.56 Increasing ﬁnancial resources, as Nabarro describes, was another motive: “We certainly needed private ﬁnancing. For the past decades, governments’ ﬁnancial contributions have dwindled. The main sources of funding are the

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private sector and the ﬁnancial markets. And since the American economy is the world’s richest, we must make the WHO attractive to the United States and the ﬁnancial markets.”57 As an expression of support for the new leadership, the Rockefeller Foundation provided Brundtland with $2.5 million to fund the recruitment of new expertise.58 In addition to private-sector ﬁnancial contributions, individuals from the private sector were recruited to prominent positions with the organization. For example, as part of Brundtland’s desire to bring “new blood” into the WHO’s senior ranks, she appointed Michael Sholtz, formerly with Ciba-Geigy and SmithKline Beecham (now GlaxoSmithKline), as head of the Health Technology Cluster. Sholtz saw his role as bridge building between the public and private sectors, and reassured potential critics of his commitment to social values: “I used to say that when I retired, I would go and work voluntarily for the WHO to pay back society. This opportunity came along and ﬁts my personal values. Now I don’t have to wait to retire. Although I have taken a substantial cut in pay, I’m very happy to be here.”59 Signiﬁcantly, there was reluctance in some cases, among the more than 50 global public-private partnerships (GPPPs) in health formed since the 1990s, to channel resources through the WHO. The most inﬂuential player, in this respect, has been the Bill and Melinda Gates Foundation. Founded in 2000, it has become the world’s largest philanthropic foundation with the doubling of its size from funds provided by Warren Buﬀet in 2006. A key focus of the Gates Foundation’s work is global health, which it has sought to improve through the creation of new initiatives, such as the Global Alliance for Vaccines and Immunization (GAVI). The WHO has been seen as a potential partner, rather than lead or coordinating agency, in such initiatives, alongside private sector partners: Private companies are delivering products to countries that aren’t on anybody’s list of top emerging markets. Merck is working with us and the government of Botswana to scale up HIV prevention and treatment in that country. It was not that long ago that a lot of smart people said you simply couldn’t treat people who were sick with AIDS in developing countries. Now, Botswana is doing it every day. … Global health issues are hard. Very hard. And it is going to take the combined expertise of all the folks in this room to help solve them. That is what I would like to talk about today—how we can work together, as partners in this push on global health. … 60 Anne-Emanuelle Birn writes that, in part-funding selected initiatives, the Foundation has inﬂuenced the decisions of other donor agencies,

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and thus global health priorities in general.61 For the WHO, it has meant a substantial bypassing of its role as the lead UN health agency. The WHO’s own eﬀorts to engage with the private sector drew concerns from within and outside the organization. As the Health Technology Cluster included the Action Programme on Essential Drugs (see Chapter 4), Sholtz’s appointment raised concerns: Dr Sholtz comes from the pharmaceutical industry and has little experience of the developing world. Dr Brundtland has portrayed the appointment as providing a liaison between the industry and the WHO. Dr Sholtz will have to prove his allegiance at a tough time for world health, when the development of eﬀective but expensive drugs for AIDS has brought to a head the north-south ﬁght over drug patent rights.62 Equally worrying were accusations that the private sector was exerting undue inﬂuence over the WHO’s formulation of clinical guidelines.63 For example, WHO guidelines on hypertension, developed in 1998 by an expert committee whose members had close ﬁnancial ties to the pharmaceutical industry, have been questioned for recommending the use of new drugs previously deemed less safe, usually no more eﬀective, and far more expensive.64 The issue prompted seven CSOs to write to Brundtland about potential conﬂicts of interest between the WHO’s public health mandate and industry involvement in its work. The letter called for greater transparency and accountability in decision making involving industry partnerships, guidelines for cooperation with the commercial sector, and the exclusion of secondment as an option for partnership arrangements between the WHO and industry.65 Despite the letter, concerns continued to be raised. Anita Hardon writes that “WHO has been criticized for relying excessively on an agreement with Novartis for the development and diﬀerential pricing of its patented anti-malarial product.”66 Daphne Fresle of the Department of Essential Drugs, who resigned in 2002 in protest over industry inﬂuence, described the Commission on Macroeconomics and Health as “much too favourable to the pharmaceutical industry.”67 To address these continued concerns, the Global Programme on Evidence for Health Policy issued the following guidelines in 2003: Public health considerations have a primary importance in all WHO technical work. Measures need to be taken to ensure that the best possible assessment of scientiﬁc evidence is achieved in an independent atmosphere free of either direct or indirect pressures.

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From international to global health Thus, to assure the technical integrity and impartiality of WHO’s work, it is necessary to avoid situations in which ﬁnancial or other interests might aﬀect the outcome of that work. Each expert is therefore asked to declare any interests that could constitute a real, potential or apparent conﬂict of interest, with respect to his/her involvement in the meeting or work, between (1) commercial entities and the participant personally, and (2) commercial entities and the administrative unit with which the participant has an employment relationship. “Commercial entity” refers to any company, association (e.g., trade association), organization or any other entity of any nature whatsoever, with commercial interests.68

A diﬀerent tension between public and private sector interests came to the fore during the WHO’s eﬀorts to adopt a Global Strategy on Diet, Nutrition and Physical Exercise. In 1989, a WHO study group on Diet, Nutrition and Prevention of NCDs issued a report by Phillip James of the International Obesity Taskforce which recommended a 10 percent limit on free sugars in a healthy diet. The sugar industry immediately lobbied to have the report withdrawn.69 A decade later, alongside the negotiation of the FCTC, the WHO looked to address other risk factors behind the worldwide surge in non-communicable diseases. In 2002 it published a Technical Report on Diet, Nutrition and the Prevention of Chronic Disease which, again, recommended, inter alia, limiting sugar intake, this time to less than 10 percent. According to Chilean nutritionist Ricardo Uauy, who chaired the Expert Group, This Expert Report is highly signiﬁcant because it contains the best currently available scientiﬁc evidence on the relationship of diet, nutrition and physical activity to chronic diseases, based on the collective judgment of a group of experts with a global perspective.70 The Sugar Association, founded in 1943 by the US sugar industry “to promote the consumption of sugar as part of a healthy diet and lifestyle through the use of sound science and research,”71 wrote to Brundtland threatening to “exercise every avenue available to expose the dubious nature” of the Report.72 A coalition of “Big Food Industries” then wrote to US Health Secretary Tommy Thompson asking him to press the WHO to withdraw the report. In response, the US government conducted a 30-page line-by-line critique of the draft document “that read as if it came from the food industry itself.”73 The document accused the WHO of a lack of scientiﬁc evidence, and

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suggested extensive changes, inserted terms, and struck out language from the text. As Sarah Boseley writes, it was a “replay [of the 1989 lobbying by the Sugar Association], but much more powerfully based, because the food industry seems to have much greater inﬂuence on the Bush government.”74 The departure of Brundtland in 2003 led to a weakened policy stance by the WHO. According to a former cabinet member, Lee softened WHO’s stance towards the food industry in exchange for US support for the 3 by 5 Initiative.75 As one WHO oﬃcial stated, It was not that easy to deal with such a powerful industry. Tensions were very strong and you cannot expect that WHO with a dozen persons in Geneva will challenge the food industry whose ﬁnancial resources far exceed WHO’s budget. … During discussions on the Global Strategy on Diet, US representatives at WHO Executive Committee never made a mystery of the fact that they would not let WHO go beyond a sanitary education focused strategy. Dr Lee had to abide by that.76 In May 2004, when the WHO formally presented the ﬁnal draft of its global strategy for approval to the WHA, the document was a weakened version of its original self. As the Executive Director of Noncommunicable Diseases, Yach, described, “Up to now, due to direct or indirect pressure, WHO has chosen not to take a stand on anything other than education because of the huge amount of money at stake within the food industry.”77 In 2007, after leaving the organization, Yach controversially joined Brundtland on PepsiCo’s Health and Wellness Advisory Board as Director of Global Health Policy. On working with the private sector he stated, I joined PepsiCo at a time of profound transformation for the company. For the last few years they have steadily moved to develop ways of addressing those aspects of the nutrition crisis that they have the power to inﬂuence … As we move forward we need to develop appropriate mechanisms of accountability for our actions. The future will judge whether the commitments and promises made by the public and private sectors have been fulﬁlled. No sector has the monopoly of what works best and what is in the public interest. We must learn to work together and responsibly.78 The right balance between public and private sector interests in global health initiatives remains the subject of ongoing debate. From the

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perspective of collaborators, the WHO remained reluctant to let go of the lead reins and form true partnerships. An evaluation of the Roll Back Malaria initiative, for example, which brought together more than 90 multilateral, bilateral, NGO and private organizations, found its loose governance structure made the concept of partnership unclear. This ﬁnding was conﬁrmed by Yamey, who observed, “A recurring theme in my interviews with WHO’s partners was their fear that WHO was using its new alliances to get back in the driver’s seat in international health policy making.”79 For those wary of undue private sector inﬂuence, WHO senior management have been accused of stiﬂing criticism of powerful companies. In 2002 the Director-General’s Oﬃce was accused of censorship.80 In March 2006, the WHO Representative in Thailand, William Aldis, was redeployed to the Southeast Asian Regional oﬃce after he published criticism of the likely impact of the US–Thai bilateral trade agreement on access to medicines.81 Others reported eﬀorts by pharmaceutical companies, such as Pﬁzer, to inﬂuence senior Thai oﬃcials via WHO auspices. Some senior WHO staﬀ have expressed concerns about possible conﬂicts of interest, as requested appointments were unrelated to the WHO’s technical assistance program with the Thai government.82 While the WHO appeared to welcome engagement with parts of the private sector, CSOs believe the same courtesies have not been aﬀorded to them. Critics have long pointed to the organization’s traditional focus on ministries of health, while formal relations with non-state (civil society and market based) institutions have been limited. In her early speeches on partnerships Brundtland gave prominence to CSOs: We are not the prime health care providers. Governments and regional authorities, NGOs and civil society are. That is why we must link up with them in a more binding and committed way. I say this openly to health ministers: You are already on board—we need to reach a broader spectrum of decision makers including ministries of ﬁnance and planning and even prime ministers and presidents—we need to reach civil society and we need to reach the private sector.83 This corresponded with support in a wide range of international organizations for enhancing the role of CSOs. The Development Assistance Committee of the OECD, for example, argued that civil society “can play a crucial role in preventing violent conﬂict and in building peace.” UNAIDS described CSOs as “at the forefront of prevention, care and support programs, particularly among the most vulnerable and hardto-reach populations.”84

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The ﬁrst People’s Health Assembly was held in 2000 as a response to perceptions that the governance of global health excluded the voices of the grassroots and the poor. While Brundtland did not attend the event, she met with CSO representatives afterwards. The meeting moved her to form the Civil Society Initiative (CSI) in 2001 to undertake a review of both oﬃcial and informal relations between WHO and Civil Society Organisations (CSOs); to develop a renewed policy for more eﬀective collaboration, information exchange and dialogue with CSOs and improve the support oﬀered by WHO to Member States in their work with NGOs and CSOs.85 The review was intended to pave the way for more diverse institutional representation in WHO activities through, for example, reforming the process of granting oﬃcial relations status and enhancing informal participation. An inventory of relations found 482 “relationships” between NGOs and WHO headquarters, of which 56 percent were “oﬃcial relations.”86 The rationale for this change was described as follows: The engagement with civil society profoundly aﬀects the ways in which international organizations understand and respond to the needs of people all over the world. Concepts about poverty, equity, justice, security, rights and responsibilities take on new meaning. Exposure to the complexities of cultures and communities hones critical thinking and sensitivity. Assumptions are challenged, power is redeﬁned, change is initiated.87 After Brundtland’s departure, under Lee and then Chan, the CSI has been largely shelved and little concrete progress has been made to enhance the role of CSOs within the WHO. Upon her nomination, Chan identiﬁed “partnerships” as one of her six priorities, and spoke of “strengthening relationships with civil society and the private sector, and creating greater alignment between partnerships.”88 Her speech on World Health Day 2007 also pointed to the need for broader engagement: Given the growing complexity of these health and security challenges and the response required, these issues concern not only governments, but also international organizations, civil society and the business community. Recognizing this, the World Health Organization is making the world more secure by working in close collaboration with all concerned.89

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Whether these statements will be translated into concrete commitments remains unclear. It is perhaps notable that, while Brundtland repeatedly cited engagement with CSOs as an important priority, in 26 oﬃcial speeches given between January and September 2007, Chan mentioned civil society only three times. In September 2007, 26 signatories including developing country governments, bilateral donors, and international organizations agreed the International Health Partnership—A Global “Compact” for Achieving the Health Millennium Development Goals.90 While the agreement commits parties to undertake such activities as “work with national stakeholders” and “engage and involve our citizens,” and private companies participate in some of the global health initiatives such as GAVI, it is perhaps notable that even the word “private” is not used in the document. The “partnership” formed is somewhat diﬀerent from earlier ones which, perhaps naively, sought to reconcile the irreconcilable. The compact is clearly government focused, both at the national level within developing countries and in the commitments from bilateral donors. Many CSOs continue to lament the diﬃculties of working with the WHO, the closed nature of its activities, and preference for GPPPs.

The trade and health agenda As well as facing competition from other institutional players in the health ﬁeld, an increasing global operating environment has required the WHO to engage with policy communities outside the health sector. The most important to date, perhaps, has been the trade policy community, brought sharply into the health domain with concerns over the adverse impact of the Agreement on TRIPS, signed in 1994, on equitable access to quality, essential medicines. These concerns led the Action Programme on Essential Drugs to publish a report in 1997 entitled Globalization and Access to Drugs, Implications of the WTO/TRIPs Agreement, which became known as the “Red Book.” The report prompted a 17-page critique by the US government, and criticism from the pharmaceutical industry that it was “a deeply ﬂawed document.” With input from the WTO and independent reviewers, a revised monograph with editorial corrections was published as the “Blue Book” in 1999.91 The report, however, maintained the core views and interpretations put forth previously.92 Adding to the WHO’s foray into trade policy, a proposed resolution on a Revised Drugs Strategy was presented to the WHA which sought to address concerns about access to medicines. Like the Red Book, the

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draft resolution caused considerable debate. A key point of contention was the following text: [Member States] ensure that public health rather than commercial interests have primacy in pharmaceutical and health policies and to review their options under the Agreement on Trade Related Aspects of Intellectual Property Rights to safeguard access to essential drugs.93 Some argued that this created a potential conﬂict between the strategy, which would place obligations (in the public interest) on member states, and obligations (largely in the pharmaceutical industry’s interests) under trade agreements, such as TRIPS. After a drafting group failed to reach consensus on a revised resolution, the EB established a two-tier approach consisting of an ad hoc working group, open to all member states wishing to participate (59 countries), and a subgroup to assist the WHO in its contact with “relevant interested parties.” At the meeting of both groups, in October 1998, technical brieﬁngs on issues concerning globalization and pharmaceuticals were presented by representatives of a wide range of stakeholders, including the WTO, World Intellectual Property Organization (WIPO), Health Action International and International Federation of Pharmaceutical Manufacturers’ Associations. The WHO Secretariat also presented strategies for ensuring access to essential medicines. While the issues raised were wide ranging, with many identiﬁed as subject to further work by the WHO, the Ad Hoc Group focused on issues covered by the resolution, namely the impact of intellectual property rights on access to medicines. In 1999, a revised resolution was presented to the WHA and this time unanimously adopted. Importantly, it urged member states “to ensure that public health interests are paramount in pharmaceutical and health policies.”94 The primacy of the WHO in monitoring the pharmaceutical and public health implications of TRIPS was established. The resolution also gave the WHO a mandate to assist countries in their eﬀorts to safeguard public health while implementing these agreements. James Love, Director of the Consumer Project on Technology, a CSO founded by Ralph Nader in 1995, described the WHA as “showing needed leadership on this issue.”95 The resolution gave the go-ahead for the WHO to expand its work on trade and health. For Brundtland, collaboration rather than confrontation between the WHO and the WTO was an important part of engaging the trade community: “We need WTO as an eﬀective and fair forum for negotiating trade rules and resolving disputes.”96 In 1999, a program

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on Globalization, Trade and Health was established. One of its ﬁrst tasks was the production of a joint study with WTO entitled WTO Agreements and Public Health.97 While public health contributors encouraged analysis that would support WHO member states in dealing with the health implications of multilateral trade agreements, the WTO sought a largely descriptive document which took a neutral stance on a number of key issues. As Brundtland remained committed to a joint report, the resultant report published in 2002 conformed with WTO wishes. Subsequent publications on trade and health, focused on the General Agreement on Trade and Services (GATS), have since been sole-authored by the WHO to allow public health concerns to be more fully considered. The issue of access to medicines, however, has remained the main barometer for assessing the WHO’s capacity to exert inﬂuence over trade policy. One positive development was the Doha Declaration and Paragraph 6 decision (see Chapter 4), which conﬁrmed ﬂexibilities to protect public health under the TRIPS agreement. Another was the creation of the Commission on Intellectual Property Rights, Innovation and Public Health in 2003 to review existing evidence on how to stimulate the creation of new medicines and other products for diseases that mainly aﬀect LMICs. The Prequaliﬁcation Project has also been well received within the public health community. Yet the WHO’s role in supporting countries has remained subject to ongoing political pressure. According to campaigners, the WHO has sought too hard to avoid direct confrontation with pharmaceutical companies and major donor countries, given its ﬁnancial vulnerability. This has been evidenced by the organization’s support for using industry-discounted rather than generic drugs,98 and its failure to speak out deﬁnitively in support of countries such as Thailand and India for seeking to protect public health.99 As Nathan Ford and Jean-Michel Piédagnel write, In the face of rising infectious diseases such as AIDS, TB, and malaria, and the increasing marginalisation of health problems that do not aﬀect the developed world, the importance of an international, independent organisation that is brave, aggressive, and vocal in its defence of global public health has never been more important.100

The global health security agenda: remaining relevant in a post-9/11 world The WHO’s eﬀorts to assert its lead role in global health have also led to the framing of selected health problems as security issues. The most obvious link between health and security, in the wake of the attack on

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the World Trade Center on 11 September 2001 (9/11) and spread of anthrax afterwards, are biological and chemical weapons. Such weapons have received long-standing attention from the WHO, which issued guidelines on their health eﬀects in 1970.101 The attempt by followers of the Rajneesh Bhagwan to spread salmonella in the United States in 1984, use of chemical weapons by the Iraqi government on its Kurdish population in 1988, new revelations from defectors of a Soviet weapons program from the late 1980s, and the Sarin gas attack on the Tokyo subway in 1995 all heightened awareness of the potential deliberate use of biological and chemical weapons. Following 9/11, the WHO called for public vigilance in responding to deliberate infections, and updated guidelines for public health responses.102 There are three lessons from recent events: ﬁrst, public health systems have responded promptly to the suspicion of deliberate infections; second, these systems must continue to be vigilant; and third, an informed and responsible public is a critical part of the response. Today we are releasing revised guidance on responses to suspected anthrax infections.103 Interestingly, 9/11 reinforced, rather than initiated, the linking of health and security within the WHO. As part of Brundtland’s diplomatic oﬀensive to raise the proﬁle of global health, in general, and the WHO in particular, she argued in the late 1990s that health should be recognized as part of the new security agenda in a post-Cold War world: [W]e need to redeﬁne the notion of security in the age of globalization. Today I will be responding to that message by saying: Yes—it is high time to revisit the notion of security and fully appreciate the role of global health for the future of your country and the entire system of international cooperation. … Global health matters for their own health and security and for the future of their children. Conditions of ill-health around the world directly and indirectly threaten the lives of large numbers of Americans.104 The initial focus of the health security agenda was communicable diseases, rather than bioterrorism, with HIV/AIDS linked most directly.105 The SARS outbreak, both its feared human cost and economic impact, added weight to the message that closer epidemiological integration of countries posed a threat to the security of all. Fears of an inﬂuenza pandemic, and calls for improved global preparedness, have also been

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framed in this way. It was these fears which led to the revision of the International Health Regulations in 2005. Setting aside assessments of the true risk posed by speciﬁc infectious diseases to global health, in the context of the WHO’s changing role, it is notable that donor governments have made strengthening of responses to communicable disease outbreaks an exception in their support of the organization. Funding has been especially forthcoming to support surveillance, reporting and response to acute infectious diseases with epidemic potential which, importantly, may pose a threat to major industrialized countries. The WHO, in turn, has recognized the leverage to be gained from the global health security discourse in the hope, perhaps, that such support can be used to reassert the organization’s standing as a whole. Thus, the theme for World Health Day 2007 and the World Health Report 2007 was international health security deﬁned in terms of disease outbreaks: We live in a world where threats to health arise from the speed and volume of air travel, the way we produce and trade food, the way we use and misuse antibiotics, and the way we manage the environment. All of these activities aﬀect one of the greatest direct threats to health security: outbreaks of emerging and epidemic-prone diseases.106

Conclusion This book has described the functioning of the WHO as an international organization formed for the purpose of fostering international cooperation in the health ﬁeld. From this analysis, two sources of tension can be identiﬁed which have regularly surfaced to deﬁne its work. The ﬁrst arises from the dichotomy between vertical and horizontal approaches to international health cooperation. What interventions are most eﬀective for improving and promoting health? Can the “highest possible level of health” be best supported through disease-focused (vertical) interventions or should attention be directed at strengthening health care and health systems (horizontal) approaches? Assessment of the scientiﬁc and technical merits of one approach or strategy over another, in terms of eﬃcacy, technical feasibility or cost-eﬀectiveness, has been the subject of ongoing research and policy debate within and beyond the WHO by epidemiologists, clinicians, health economists and others within the public health community. A closely related dichotomy is the tension between a focus on health and disease versus the broader determinants of health. Traditionally,

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the WHO has largely focused on the former, as reﬂected in the expertise of its staﬀ, institutional structure, and working relationships. The issue of access to essential medicines, regulation of the marketing of breast milk substitutes, and the Health for All strategy brought new realizations that health goals needed to be tackled alongside attention to forces outside of the health sector. Since the 1990s, recognition of the importance of economic, trade and security policy to health has brought additional pressures for the WHO to broaden its strategic vision and adapt its ways of working. Over the past six decades, the WHO’s navigation of these two sources of tension has never been far removed from broader political, economic and ideological forces at play. Ostensibly, the WHO’s role is to act as the UN specialized agency responsible for fostering international cooperation among its member states. From the beginning, however, the WHO has been built on political compromise. Its creation in 1948 required the integration of existing bodies, with established mandates and organizational cultures, into a new institutional structure. As well as a headquarters, the WHO established regional and country oﬃces to give voice to its diverse member states. Its agreed Constitution then embraced the breadth of the goals and aspirations of its creators, resulting in a progressively broad concept of health, accompanied by a daunting list of functions. Finally, resources have been collected and then allocated across numerous programs and the organization’s three operating levels, giving eﬀect to these functions. The universality of the WHO’s membership, in other words, has required it to balance many diﬀerent interests and demands. What resources should each country and region receive? What health conditions should the WHO give priority to? Whose voices exert inﬂuence within the organization and whose are excluded? What values should drive decision making—allocative eﬃciency, social justice or another set of norms? Crucially, the organizational challenges faced by the WHO have reﬂected the broader context within which it has operated. The WHO’s mandate was broadly deﬁned by post-Second World War functionalism, yet constrained by Cold War realism. The organization found itself treading carefully between the two. The proclivity during the 1960s of development theorists to support major infrastructure projects similarly inﬂuenced the WHO’s activities. The 1970s and 1980s brought new ideas about development, including dependency theory, and an unprecedented assertiveness in the developing world. Led by the Non-Aligned Movement, many LMICs sought to reform the underpinnings of the post-war order which were seen as inherently unfair. The debates over essential medicines, Health for All and breast

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milk substitutes were a direct product of these broader trends. The ascendance of neoliberalism from the 1980s, in the US and other leading economies, as well as the World Bank, the IMF and other international economic institutions, also directly impacted on the WHO’s work. From challenging neoliberalism in the 1980s, by the late 1990s some accused the WHO of “selling out” by developing closer links with the World Bank, the WTO and the private sector. Others argued that the organization had not gone far enough in embracing change, and chose to channel resources to new global health initiatives. In seeking to adapt to the emerging global health milieu, in recent years the WHO has been required to navigate the two dichotomies described above among an unprecedented range of institutions, ideas and interests. In 1952, Ascher lamented the presence of politics in the WHO, stating that “if only the politicians would get out of their way, WHO could really put on a program for world health.”107 This book argues that politics has been invariably embedded in the WHO throughout its history. The challenge is not to somehow remove politics from the organization, but rather to ensure its healthier political functioning. If the WHO were a patient, a clinical assessment at 60 years of age would conclude that certain parts of the organization remain robust, if somewhat circumscribed in their capacities. There are clear battle scars, earned from internal rivalries for limited resources and external scraps with competitors and detractors. In the early twenty-ﬁrst century, it faces continued pressure to become leaner and meaner, given strong dependence on major donors and the powerful economic interests who inﬂuence them. At the same time, this must somehow be reconciled with its role as the world’s health organization, created to ensure “the attainment by all peoples of the highest possible level of health.” These competing notions of the WHO’s role have led to critics and supporters in equal measure, most wishing the organization to succeed, but having very diﬀerent perspectives on what should be achieved.

Notes

Forward 1 See Craig Murphy, International Organization and Industrial Change: global governance since 1850 (Cambridge: Polity, 1994). 2 See David P. Forsythe and Barbara Ann J. Rieﬀer-Flanagan, The International Committee of the Red Cross: a neutral humanitarian actor, (London: Routledge, 2007). 3 See Steve Hughes and Nigel Haworth, The International Labour Organization (London: Routledge, forthcoming) and Richard Jolly, UNICEF (London: Routledge, forthcoming). 4 See, for example, Steve Hughes and Nigel Haworth, The International Labour Organization (London: Routledge, forthcoming); Gil Loescher, Alexander Betts, and James Milner, UNHCR: the politics and practice of refugee protection into the twenty ﬁrst century (London: Routledge, 2008); and, Elizabeth A. Mandeville and Craig N. Murphy, The United Nations Development Programme (UNDP) (London: Routledge, forthcoming). 5 Elizabeth DeSombre, Global Environmental Institutions (London: Routledge, 2006). 6 See WHO, “Update 37 – WHO extends its SARS-related travel advice to Beijing and Shanxi Province in China and to Toronto Canada,” available at: http://www.who.int/csr/sars/archive/2003_04_23/en/ 7 See, for example, Kelley Lee, ed., Health Impacts of Globalization: towards global governance (New York: Palgrave Macmillan, 2003); Kelley Lee, Globalization and Health: an introduction (New York: Palgrave Macmillan, 2004); Kelley Lee, Historical Dictionary of the World Health Organization (Lanham, MD: The Scarecrow Press, Inc., 1998); and, Kelley Lee and Jeﬀ Collin, eds., Global Change and Health (New York: Open University Press, 2005). Introduction 1 See Alfred Crosby, The Columbian Exchange: biological consequences of 1492 (Westport, CT: Greenwood Press, 1972). 2 See Sheldon Watts, Disease and Medicine in World History (London: Routledge, 2003).

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3 F.H. Garrison, An Introduction to the History of Medicine (Philadelphia: WB Saunders, 1929). 4 Covenant of the League of Nations, New York, 28 April 1919, Article 23(f). 5 Octavio Gómez-Dantés, “International Health in the 20th Century: agenda, negotiations and agreements,” Salud Pública de México 45, no. 4 (2003): 316–32. 6 International Red Cross and Red Crescent Movement, Red Cross and Red Crescent: portrait of an international movement (Geneva: ICRC, 1992). 7 WHO, The First Ten Years of the World Health Organization (Geneva: 1958). 8 PAHO, Pro Salud Novi Mundi, A History of the Pan American Health Organization (Washington, D.C.: 1992). 9 Elizabeth Fee and Theodore M. Brown, “100 Years of the Pan American Health Organization,” American Journal of Public Health 92, no. 12 (December 2002): 1888–89. 10 K. Celeste Gaspari and Arthur Woolfe, “Income, Public Works and Mortality in Early Twentieth Century American Cities,” Journal of Economic History 45, no. 2 (June 1985): 355–61. 11 George Rosen, A History of Public Health (Baltimore, MD: Johns Hopkins University Press, 1993). 12 D. Porter, “How Did Social Medicine Evolve, and Where is it Heading?,” PLoS Medicine 3, no. 10 (October 2006): 1667–72. 13 Ibid. 14 For example see Robert Bedeski, “UN agencies must be depoliticized,” Taiwan Journal (13 May 2005). 15 Charles E. Allen, “World Health and World Politics,” International Organization, 4, no. 1 (February 1950): 27–43. 16 David Mitrany, A Working Peace System: an argument for the functional development of international organization (London: Royal Institute of International Aﬀairs, 1943). 1 Creation of the World Health Organization 1 WHO, Report on Global Surveillance of Epidemic-prone Infectious Diseases (Geneva: Epidemic and Pandemic Alert and Response, 2007). 2 Adrian Bingham, “The British Popular Press and Venereal Disease during the Second World War,” The Historical Journal, 48, no. 4 (December 2005): 1055–76. 3 Oﬃcial Records of the World Health Organization, 1 (1948): 39. 4 Ibid. 5 Yves Beigbeder, L’Organisation Mondial de la Santé (Paris: PUF, 1997). 6 Constitution of the World Health Organization, 1946, Preamble. 7 Ibid., Article 2. 8 Intergovernmental Working Group on Revision of the International Health Regulations, “Review and Approval of Proposed Amendments to the International Health Regulations,” A/IHR/IGWG/2/INF.DOC./2, Second Session, Provisional agenda item, 27 January 2005, http://ftp.who. int/gb/ghs/pdf/IHR_IGWG2_ID2-en.pdf 9 WHO, Engaging for Health, Eleventh General Programme of Work, A Global Health Agenda (Geneva: 2005).

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10 Monitoring the 11th General Programme of Work, Addendum for the World Health Assembly, May 2006. 11 Roger Bate, “WHO’s AIDS Target: An Inevitable Failure,” Health Policy Outlook, no. 3 (2006), American Enterprise Institute for Public Policy Research,www.aei.org/publications/pubID.23712/pub_detail.asp 12 Joungwon Alexander Kim and Carolyn Campbell Kim, “The Divided Nations in the International System,” World Politics, 25, no. 4 (July 1973): 479–507. 13 “Taiwan Makes Plea for WHO Membership,” Washington Post, 11 May 2007, www.washingtonpost.com/wp-dyn/content/article/2007/05/11/AR2007 051101087_pf.html 14 Paul Lewis, “P.L.O. Starts Eﬀort to Raise Status at U.N. Health Agency,” New York Times, 20 April 1989, http://query.nytimes.com/gst/fullpage.html? res=950DE4D7133CF933A15757C0A96F948260&n=Top%2FReference%2 FTimes%20Topics%2FOrganizations%2FU%2FUnited%20Nations%20 15 Paul Lewis, “UN Health Agency Seeks Compromise on P.L.O.,” New York Times, 7 May 1989, http://query.nytimes.com/gst/fullpage.html?res=950 DE7D91138F934A35756C0A96F948260&n=Top%2fReference%2fTimes% 20Topics%2fOrganizations%2fU%2fUnited%20Nations%20 16 “U.N. Agency Rejects P.L.O. Role,” New York Times, 11 May 1990, http://query.nytimes.com/gst/fullpage.html?res=9C0CE2D9103FF932A25756 C0A966958260&n=Top%2fReference%2fTimes%20Topics%2fOrganizations %2fW%2fWorld%20Health%20Organization 17 WHO, “Aligning the Participation of Palestine in the World Health Organization with its Participation in the United Nations,” 53rd WHA, A53/ 40, 19 May 2000, http://ftp.who.int/gb/archive/pdf_ﬁles/WHA53/ea40.pdf 2 Structure and functions 1 As quoted in Fiona Godlee, “The World Health Organisation: Interview with the Director General,” BMJ 31, no. 6979 (3 March 1995): 583–88. 2 Gro Harlem Brundtland, “Address to Permanent Missions in Geneva,” Geneva, 10 November 1998, www.who.int/director-general/speeches/1998/ english/19981110_missions.html 3 Gro Harlem Brundtland, “Meeting of Interested Parties – Opening Remarks,” Geneva, 18 June 2001, www.who.int/director-general/speeches/2001/english/ 20010618_mipgeneva2001.en.html 4 WHO, “Dr Brundtland addresses the WHO staﬀ and the press,” Geneva, Switzerland, 21 July 1998, www.who.int/director-general/speeches/1998/ index.html 5 Adrea Mach, “Brundtland Replaces Top Staﬀ at WHO,” BMJ 317, no. 7153 (25 July 1998): 229. 6 WHO, “Dr Brundtland addresses the WHO staﬀ and the press.” 7 In the Americas, the regional committee is known as the Directing Council. 8 Fraser Brockington, World Health (Edinburgh: Churchill-Livingston, 1975), 154. 9 H.S. Gear, “The World Health Organization. New York Conference, 1946,” South African Medical Journal 20, (1946): 515–17. 10 Fiona Godlee, “Change at Last at WHO: but will the regions play ball?,” BMJ 317, no. 7154 (1 August 1998): 296.

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11 WHO, “Dr Gro Harlem Brundtland, Director-General Elect, The World Health Organization, Speech to the Fifty-ﬁrst World Health Assembly, Geneva,” 51st WHA, A51/DIV/6, 3 May 1998, www.who.int/directorgeneral/speeches/1998/english/dgspeech%20wha98%20eadiv6.pdf 12 GavinYamey, “WHO in 2002: Have the Latest Reforms Reversed WHO’s Decline?” BMJ 325, no. 7372 (9 November 2002): 1107–12. 13 Malaria Consortium, Final Report of the External Evaluation of Roll Back Malaria, Achieving Impact (London: London School of Hygiene & Tropical Medicine and Liverpool School of Tropical Medicine, November 2002), www.igh.ucsf.edu/publications/roll_back_malaria.pdf 14 Ruth Levine, “Open Letter to the Incoming Director General of the World Health Organization: Time to Refocus,” BMJ 333, no. 7576 (11 November 2006): 1015–17. 15 For a map showing WHO country oﬃces see www.who.int/countryfocus/ country_oﬃces/map_showing_who_country_oﬃces.pdf 16 WHO, WHO Country Oﬃces and Country Focus, Report by the Secretariat, Executive Board 111th Session, EB116/6, Geneva, 21 April 2005, www. who.int/gb/ebwha/pdf_ﬁles/EB116/B116_6-en.pdf 17 Adetokunbo Lucas, Sigrun Mogedal, Gill Walt, Sissel Hodne Steen, Stein Erik Kruse, Kelley Lee and Laura Hawken, Cooperation for Health Development, The World Health Organisation’s Support to Programmes at Country Level (London: London School of Hygiene & Tropical Medicine, 1997). http://whqlibdoc.who.int/publications/0N02657577_V1_ (ch1-ch2).pdf 18 WHO, WHO Country Oﬃces: Criteria for Classifying Countries on the Basis of Need, Report by the Director-General, Executive Board, 102nd Session, EB102/2, Geneva, 27 April 1998, http://ftp.who.int/gb/pdf_ﬁles/ EB102/ee2.pdf 19 WHO, Review of the Constitution and Regional Arrangements of the World Health Organization, Report of the Special Group, Executive Board, 101st Session, Provisional agenda item 7.3, EB101/7, Geneva, 1997. 20 WHO, Regular Budget Allocations to Regions, Resolution of the Executive Board, 101st Session, Agenda Item 7.3, EB101.R10; and Resolution WHA51.31, Geneva, 1998. 21 WHO, Working within and with Countries, Report by the DirectorGeneral, Executive Board, EB105/7, Geneva, 15 December 1999, http:// ftp.who.int/gb/pdf_ﬁles/EB105/ee7.pdf 22 WHO, Country Focus Initiative, Report by the Director-General, Executive Board, 111th Session, EB111.33, Geneva, 10 December 2002, www.who. int/gb/ebwha/pdf_ﬁles/EB111/eeb11133.pdf 23 Ibid. 24 WHO, Constitution of the World Health Organization, 1948, Article 57. 25 WHO, Organizational Study on the Planning for and Impact of Extrabudgetary Resources on WHO’s Programmes and Policy, Executive Board, 57th Session, EB57/25, Geneva, 1975. 26 J. Patrick Vaughan, Sigrun Mogedal, Stein Erik Kruse, Kelley Lee, Gill Walt and K. de Wilde, “Financing the World Health Organization: Global Importance of Extrabudgetary Funds,” Health Policy 35 (March 1996): 229–45.

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27 J. Patrick Vaughan, Sigrun Mogedal, Stein-Erik Kruse, Kelley Lee, Gill Walt and Koen de Wilde, Cooperation for Health Development, Extrabudgetary Funds in the World Health Organisation (London: Governments of Australia, Norway and the UK, 1995). 28 WHO, Extrabudgetary Resources: A Policy Framework, Report by the Secretariat, Executive Board, 104th Session, EB 104/3, Geneva, 23 April 1999, http://ftp.who.int/gb/pdf_ﬁles/EB104/ee3.pdf 29 WHO, Status of Collection of Assessed Contributions Including Members in Arrears to an Extent which would Justify Invoking Article 7 of the Constitution, Report by the Director-General, Executive Board, 109th Session, Provisional Agenda Item 5.1, EB109/20, Geneva, 20 December 2001, http://ftp.who.int/gb/ebwha/pdf_ﬁles/EB109/eeb10920.pdf 30 Afghanistan, Antigua and Barbuda, Argentina, Armenia, Central African Republic, Chad, Comoros, Dominican Republic, Georgia, Guinea-Bissau, Iraq, Kyrgyzstan, Liberia, Nauru, Niger, Republic of Moldova, Somalia, Suriname, Tajikistan and Turkmenistan. 31 WHO, Special Arrangements for Settlement of Arrears, WHA, 58th Session, Agenda Item 17.3, A58/43 Rev.1, Geneva, 18 May 2005, www. who.int/gb/ebwha/pdf_ﬁles/WHA58/A58_43Rev1-en.pdf 32 Elizabeth Olson, “Other Nations Balk at Picking up Tab: UN Health Agency Reduces US Dues,” International Herald Tribune, 23 May 2001, www.iht.com/articles/2001/05/23/who_ed3_.php 33 Ibid. 34 Barry R. Bloom, David E. Bloom, Joel E. Cohen, Jeﬀrey D. Sachs, “Investing in the World Health Organization,” Science 284, no. 5416 (7 May 1999): 911. 35 Kelley Lee and Kent Buse, “Assuming the Mantle: The Balancing Act Facing the New WHO Director-General,” Journal of the Royal Society of Medicine 99, no. 10 (October 2006): 494–96. 36 WHO, Guiding Principles for Strategic Resource Allocations, Executive Board, 116th Session, EB116/5, Geneva, 18 April 2005, www.who.int/gb/ ebwha/pdf_ﬁles/EB116/B116_5-en.pdf 3 Global campaigns against disease 1 UNICEF, The State of the World’s Children 1996 (New York: 1996), www.unicef.org/sowc96/1950s.htm 2 Alexandra Minna Stern and Howard Markel, “International Eﬀorts to Control Infectious Diseases, 1851 to the Present,” JAMA 292, no. 12 (22 September 2004): 1474–79. 3 C.L. Gonzalez, Mass Campaigns and General Health Services (Geneva: WHO, 1965). 4 Anne Mills, “Mass Campaigns Versus General Health Services: What Have We Learnt in 40 Years About Vertical Versus Horizontal Approaches?” Bulletin of the World Health Organization 83, no. 4 (April 2005): 315–16. 5 P.I. Trigg and A.V. Kondrachine, “Commentary: Malaria Control in the 1990s,” Bulletin of the World Health Organization, 76, no. 1 (1998): 11–16. 6 Rachel Carson published her inﬂuential book on environmental pollution, Silent Spring (New York: Houghton Miﬄin, 1962), which is credited

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18 19

20 21 22 23 24

25

Notes with launching the environmental movement. The book includes condemnation of the eﬀects of DDT and other pesticides on wildlife, notably wild birds, which contributed to the banning of its use in the US in 1972. Médecins sans Frontières, ACT NOW to Get Malaria Treatment That Works to Africa (Geneva: MSF Campaign for Access to Essential Medicines, 2003), www.accessmed-msf.org/documents/malariaACTNOWhigh.pdf Donald Henderson, “Eradication: Lessons from the Past,” Morbidity and Mortality Weekly Report, no. 48, Supplement 1 (1999): 16. Brian Greenwood, as quoted in Michael Balter, “Can WHO Roll Back Malaria?” Science 290, no. 5491 (20 October 2000): 430. Médecins sans Frontières, ACT NOW. Trigg and Kondrachine, “Commentary: Malaria Control in the 1990s.” Ibid. As quoted in Monique Eid, “Malaria, a Parasite Laughing at Cheap Drugs,” UNSpecial, no. 605 (March 2002), www.unspecial.org/uns605/ UNS_605_F_T13.html As quoted in Michael Finkel, “Bedlam in the Blood: Malaria,” National Geographic (July 2007), www7.nationalgeographic.com/ngm/0707/feature1/ index.html Donald R. Roberts, Larry L. Laughlin, Paul Hsheih and Llewellyn J. Legters, “DDT, Global Strategies, and a Malaria Control Crisis in South America,” Emerging Infectious Diseases 3, no. 3 (July–September 1997): 295–302. WHO, “WHO Gives Indoor Use of DDT a Clean Bill of Health for Controlling Malaria,” News Release, 15 September 2006, www.who.int/ mediacentre/news/releases/2006/pr50/en/ WHO, Containment of Malaria Multi-Drug Resistance on the CambodiaThailand Border, Report of an Informal Consultation (New Delhi: SouthEast Asian Regional Oﬃce/Western Paciﬁc Regional Oﬃce, 2007), www. who.int/malaria/docs/drugresistance/ReportThaiCam.pdf Eliot Marshall, “A Renewed Assault on an Old and Deadly Foe,” Science 290, no. 5491 (20 October 2000): 428–30. J. Anderson, M. MacLean and C. Davies, Malaria Research, an Audit of International Activity, Unit for Policy Research in Science and Medicine (London: Wellcome Trust, 1996), www.wellcome.ac.uk/assets/ wtd003220.pdf Médecins sans Frontières, ACT NOW. Eid, “Malaria, a Parasite Laughing at Cheap Drugs.” Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, “How the Global Fund Works,” available at www.theglobalfund.org/en/about/how/. John Donnelly, “World Health Fund has New Director, New Challenges,” Boston Globe, 22 April 2007, www.boston.com/news/nation/washington/ articles/2007/04/22/world_health_fund_has_new_director_new_challenges/ Amir Attaran, K.I. Barnes, Chris Curtis, U. d’Alessandro, C.I. Fanello, M.R. Galinski, G. Kokwaro, S. Looareesuwan, M. Makanga, T.K. Mutabingwa, A. Talisuna, J.F. Trape and W.M. Watkins, “WHO, the Global Fund, and Medical Malpractice in Malaria Treatment,” Lancet 363, no. 9404 (17 January 2004): 237–40. “WHO Refutes Malaria Malpractice Allegations,” Bulletin of the World Health Organization 82, no. 3 (March 2004): 237.

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26 Christiane Rehwagen, “Send for Kochi,” BMJ 333, no. 7559 (15 July 2006): 116. 27 Eid, “Malaria, a Parasite Laughing at Cheap Drugs.” 28 Donald Henderson, “Principles and Lessons from the Smallpox Eradication Programme,” Bulletin of the World Health Organization 65, no. 4 (April 1987): 535–46. 29 T.B. Macaulay, The History of England from the Accession of James II, (London: J.M. Dent and Sons, 1800). 30 Michael Oldstone, Viruses, Plagues and History (Oxford: Oxford University Press, 2004). 31 Frank Fenner, Donald Henderson, Isao Arita, Zdeneˇ k Ježek and Ivan Ladnyi, Smallpox and its Eradication (Geneva: World Health Organization, 1988). 32 Ibid. 33 Henderson, “Principles and Lessons from the Smallpox Eradication Programme.” 34 Fenner et al., Smallpox and its Eradication. 35 Ibid. 36 Ibid. 37 Henderson, “Principles and Lessons from the Smallpox Eradication Programme.” 38 Paul Greenough, “Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign, 1973–75,” Social Science and Medicine 41, no. 5 (September 1995): 633–45. 39 Donald Henderson, “Eradication: Lessons from the Past,” Morbidity and Mortality Weekly Report 48 (Supplement 1) (31 December 1999): 16–22. 40 Ibid. 41 Jeﬀrey Drazen, “Smallpox and Bioterrorism,” New England Journal of Medicine 346, no. 17 (25 April 2002): 1262–63. 42 Veronique de Rugy and Charles Peña, Responding to the Threat of Smallpox Bioterrorism an Ounce of Prevention is Best Approach (Washington, D.C.: Cato Institute, 2002), www.cato.org/pubs/pas/pa434.pdf 43 Tommy Thompson, “United States Pledges 20 Million Doses of Smallpox Vaccine to Global Stockpile,” News Release, US Department of Health and Human Services, 10 December 2004, www.os.dhhs.gov/news/press/ 2004pres/20041210a.html 44 Drazen, “Smallpox and Bioterrorism.” 45 As quoted in Barton Gellman, “Death Watch, The Global Response to AIDS in Africa, World Shunned Signs of the Coming Plague,” Washington Post, 5 July 2000, www.washingtonpost.com/ac2/wp-dyn? pagename=article&node=&contentId=A47234–2000Jul4 46 Elizabeth Fee, The WHO Response to the HIV/AIDS Pandemic, Geneva, WHO, 6 September 2006, www.who.int/global_health_histories/seminars/ presentation08.pdf 47 Elizabeth Fee and Theodore Brown, “Voices from the Past: Michael S. Gottlieb and the Identiﬁcation of AIDS,” American Journal of Public Health 96, no. 6 (June 2006): 982–83. 48 Jonathan Mann, “AIDS: A Worldwide Pandemic,” in M.S. Gottlieb, D.J. Jeﬀries, D. Mildvan, A.J. Pinching and T.C. Quinn, eds., Current topics in AIDS, Vol. 2 (New York: John Wiley & Sons, 1989). 49 Gellman, “Death Watch.”

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50 Jonathan Mann, S. Gruskin, M.A. Grodin and G.J. Annas, eds., Health and Human Rights: A Reader (New York: Routledge, 1999). 51 WHO, Avoidance of Discrimination Against HIV-Infected Persons and Persons with AIDS, WHA, Resolution WHA41.24, Geneva, 13 May 1988. 52 As quoted in B.L. Ligon-Borden, “Dr. Jonathan Mann: Champion for Human Rights in the Fight Against AIDS,” Seminars in Pediatric Infectious Diseases 14, no. 4 (October 2003): 314–22. 53 Barton Gellman, “Death Watch.” 54 Jean-Louis Lamboray, Combatting AIDS and other Sexually Transmitted Diseases in Africa: A Review of the World Bank’s Agenda for Action, (Washington, D.C.: Africa Technical Department, 1992). 55 World Bank, AIDS Prevention and Mitigation in Sub-Saharan Africa, An Updated World Bank Strategy (Washington, D.C.: Africa Technical Department, 1996). 56 External Review Committee, Report of the External Review of the World Health Organization Global Programme on AIDS, Geneva, (January 1992): 41–43. 57 Peter Piot, “New UN Program Promotes Multisectoral Approach to AIDS Prevention,” AIDScaptions (May 1996): 34–37. 58 Barton Gellman, “Death Watch.” 59 Larry Gostin, “Public Health, Ethics, and Human Rights: A Tribute to the Late Jonathan Mann,” Journal of Law, Medicine & Ethics 29, no. 2 (Summer 2001): 121–30. 60 Sandra Thurman, Director of the White House Oﬃce of National AIDS Policy as quoted in Barton Gellman, “Death Watch, The Global Response to AIDS in Africa.” 61 Barton Gellman, “Death Watch.” 62 UN ECOSOC, Joint and Co-sponsored United Nations Programme on Human Immunodeﬁciency Virus/Acquired Immunodeﬁciency Syndrome (HIV/AIDS), Resolution 1994/24, 44th Plenary Meeting, 26 July 1994, www.un.org/documents/ecosoc/res/1994/eres1994–24.htm 63 Helen Elsey and Prisca Kutengule, HIV/AIDS Mainstreaming: A Deﬁnition, Some Experiences and Strategies (Liverpool: Liverpool School of Tropical Medicine, January 2003), www.nu.ac.za/heard/research/ ResearchReports/2003/DFID%20mainstreaming%20report_Jan031.pdf 64 WHO, Global Health-Sector Strategy for HIV/AIDS, 2003–2007 (Geneva: Department of HIV/AIDS, 2003), www.who.int/hiv/pub/advocacy/GHSS _E.pdf 65 Barton Gellman, “Death Watch.” 66 UNAIDS, Final Report, Five-Year Evaluation of UNAIDS (Geneva: October 2002), http://data.unaids.org/Governance/PCB03/pcb_13_02_02_ en.pdf 67 Jim Yong Kim and Arthur Ammann, “Debate: is the ‘3 by 5’ Initiative the Best Approach to Tackling the HIV Pandemic?,” PLoS Medicine 1, no. 2 (November 2004): 97–100. 68 Jennifer Prah Ruger and Derek Yach, “Global Functions at the World Health Organization,” BMJ 330, no. 7500 (14 May 2005): 1099–1100. 69 Kim and Ammann, “Debate.” 70 Group of Eight, The Gleneagles Communiqué, 2005, www.fco.gov.uk/ Files/kﬁle/PostG8_Gleneagles_Communique.pdf

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71 UN General Assembly, “2005 World Summit Outcome,” Draft Resolution Referred to the High-level Plenary Meeting of the General Assembly by the General Assembly at its 59th Session, New York, 15 September 2005, www.who.int/hiv/universalaccess2010/worldsummit.pdf 72 US State Department, “About PEPFAR,” Oﬃce of US Global AIDS Coordinator and the Bureau of Public Aﬀairs, Washington, D.C., www. pepfar.gov/about/ 73 UNAIDS, The “Three Ones” in Action: Where We Are and Where We Go From Here (Geneva: 2005), http://data.unaids.org/publications/irc-pub06/ jc935–3onesinaction_en.pdf 74 UNAIDS, Global Facts and Figures (Geneva: December 2006), http:// data.unaids.org/pub/EpiReport/2006/20061121_EPI_FS_GlobalFacts_en.pdf 75 Dylan Williams, “World Health: A Lethal Dose of US Politics,” Asia Times (17 June 2006). 76 Paul Benkimoun, “How Lee Jong-wook Changed WHO,” Lancet 367, no. 9525 (3 June 2006): 1806–8. 77 UNAIDS, Global Facts and Figures. 78 Anthony Fauci as quoted in “World Losing Fight against Aids,” BBC News, 23 July 2007, http://news.bbc.co.uk/1/hi/world/asia-paciﬁc/6911736.stm. 79 C. Sathyamala, Onkar Mittal, Rajib Dasgupta and Ritu Priya, “Polio Eradication Initiative in India: Deconstructing the GPEI,” International Journal of Health Services 35, no. 2 (2005): 361–83. 80 William Muraskin, The Politics of International Health: The Children’s Vaccine Initiative and the Struggle to Develop Vaccines for the Third World (New York: State University of New York Press, 1998). 81 Ibid. 82 Ibid. 83 Haroon Ashraf, “WHO Takes Another Step towards Polio Eradication,” Lancet 359, no. 9325 (29 June 2002): 2255. 84 “The WHO European Region Declared Free of Polio,” Euro Surveillance Bulletin 7, no. 5 (May 2002): 76–77. 85 Fiona Fleck “WHO Warns of a Polio Epidemic in Africa,” BMJ 328, no. 7455 (26 June 2004): 1513. 86 Global Polio Eradication Initiative, Annual Report 2006 (Geneva: WHO/ Rotary International/CDC/UNICEF, 2006), www.polioeradication.org/ content/publications/AnnualReport2006_ENG01.pdf 87 Global Polio Eradication Initiative, Monthly Situation Reports, December 2006, www.polioeradication.org/content/general/poliositrepNovember2006. asp 88 Sathyamala et al., “Polio Eradication Initiative in India.” 89 WHO, “Poliomyelitis,” Fact Sheet No. 114, September 2006, www.who. int/mediacentre/factsheets/fs114/en/ 4 Tackling the broad determinants of health 1 WHO, Health Promotion Glossary (Geneva: 1998). 2 Public Health Agency of Canada, Canada’s Response to WHO Commission on Social Determinants of Health, Glossary (Ottawa: Government of Canada, 2007), www.phac-aspc.gc.ca/sdh-dss/glos_e.html 3 Chandrakant Lahariya, Hyoti Khandekar and Joseph G. Prasuna, “A Critical Review of National Rural Health Mission in India,” Internet

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12 13 14 15 16 17 18 19 20 21 22 23

Notes Journal of Health 6, no. 1 (2007), www.ispub.com/ostia/index.php?xmlFile Path=journals/ijh/vol6n1/mission.xml Richard Titmuss, “The Health Services of Tanganyika: A Report to the Government” Medical Care 2, no. 1 (January-March 1964): 27–29. George J. Schieber and Jean-Pierre Poullier, “International Health Spending: Issues and Trends,” Health Aﬀairs 10, no. 1 (Spring 1991): 106–16, http:// content.healthaﬀairs.org/cgi/reprint/10/1/106.pdf John H. Bryant, Health and the Developing World (New York: Cornell University Press, 1969). Kenneth Newell, Health by the People (Geneva: WHO, 1975). Carl Taylor, Doctors for the Villages: Study of Rural Internships in Seven Indian Medical Colleges (New York: Asia Publishing House, 1976). Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care,” American Journal of Public Health 94, no. 11 (November 2004): 1864–74. Halfdan Mahler, “Social Perspectives in Health: Address in Presenting his Report for 1975 to the Twenty-Ninth World Health Assembly, Geneva, 4 May 1976,” 1, Mahler Speeches/Lectures, Box 1, WHO Library. WHO, “WHO Called to Return to the Declaration of Alma-Ata International Conference on Primary Health Care,” Commission on the Social Determinants of Health, Geneva, 2007, www.who.int/social_deter minants/links/events/alma_ata/en/index.html Kelley Lee, “The Pit and the Pendulum: Can Globalization Take Health Governance Forward?,” Development 47, no. 2 (June 2004): 11–17. J.A. Walsh and K.S. Warren, “Selective Primary Health Care: An Interim Strategy for Disease Control in Developing Countries,” New England Journal of Medicine 301, no. 18 (1 November 1979): 967–74. Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care.” Lesley Magnussen, John Ehiri and Pauline Jolly, “Comprehensive versus Selective Primary Health Care: Lessons for Global Health Policy,” Health Aﬀairs 23, no. 3 (May/June 2004): 167–76. Kenneth S. Warren, “The Start of a Global Health Strategy,” Current Contents (Institute for Scientiﬁc Information), (13 December 1993): 11. www.garﬁeld.library.upenn.edu/classics1993/A1993MH50900004.pdf Magnussen, et al., “Comprehensive versus Selective Primary Health Care: Lessons for Global Health Policy.” WHO, Indicators for Monitoring Progress Towards Health for All by the Year 2000, Primary Health: A First Assessment, Geneva, 1981. Kenneth Newell, “Selective Primary Health Care: The Counter Revolution,” Social Science and Medicine 26, no. 9 (1988): 903–6. David Werner, Where There is No Doctor (Berkeley: Hesperian Foundation, 1983). David Werner, “Elusive Promise, Whatever Happened to ‘Health for All?,’” New Internationalist 331 (January/February 2001), www.newint.org/ issue331/elusive.htm Ibid. Susan Rifkin and Gill Walt, “Why Health Improves: Deﬁning the Issues Concerning ‘Comprehensive Primary Health Care’ and ‘Selective Primary Health Care’,” Social Science and Medicine 23, no. 6 (1986): 559–66.

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24 David de Ferranti, Financing Health Services in Developing Countries (Washington, D.C.: World Bank, 1983). 25 World Bank, World Development Report: Investing in Health (Washington, D.C.: International Bank for Reconstruction and Development, 1993). 26 Marcos Cueto, “The Origins of Primary Health Care and Selective Primary Health Care.” 27 Kelley Lee and Hilary Goodman, “Global Policy Networks: the Propagation of Health Care Financing Reforms from the 1980s,” in Kelley Lee, Kent Buse and Suzanne Fustukian eds., Health Policy in a Globalising World (Cambridge: Cambridge University Press, 2002): 97–119. 28 Zafrullah Chowdhury and Michael Rowson, “The People’s Health Assembly, Revitalising the Promise of ‘Health for All’,” BMJ 321, no. 7273 (2 December 2000); 1361–62. 29 Gro Harlem Brundtland, “Letter: The People’s Health Assembly,” BMJ 323, no. 7304 (14 July 2001): 109. 30 Caroline Thomas and Martin Weber, “The Politics of Global Health Governance: Whatever Happened to ‘Health for All by the Year 2000’?,” Global Governance 10, no. 2 (April/June 2004): 187–205. 31 William Foege, “Global Public Health: targeting inequities,” JAMA 279, no. 24 (24 June 1998): 1931–32. 32 Danny Dorling, Mary Shaw and George Davey Smith, “Global Inequality of Life Expectancy due to AIDS,” BMJ 332, no. 7542 (18 March 2006): 662–64. 33 Jennifer Prah Ruger and H.J. Kim, “Global Health Inequalities: An International Comparison,” Journal of Epidemiology and Community Health 60 (2006): 928–36. 34 Lesley Magnussen, John Ehiri and Pauline Jolly, “Comprehensive Versus Selective Primary Health Care: Lessons for Global Health Policy,” Health Aﬀairs 23, no. 3 (May/June 2004): 167–76. 35 Edward Baer as quoted in Kathryn Sikkink, “Codes of Conduct for Transnational Corporations: The Case of the WHO/UNICEF Code,” International Organization 40, no. 4 (Autumn 1986): 815–40. 36 S.J. Plank and M.L. Milanesi, “Infant Feeding and Infant Mortality in Rural Chile,” Bulletin of the World Health Organization 48, no. 2 (February 1973): 203–120. 37 WHO, Resolutions WHA27.43 and WHA 31.47 in Handbook of Resolutions and Decisions of the WHA and the Executive Board, Vol II, 4th edition (Geneva: 1981): 58 and 62. 38 Quoted in Edward Baer and Leah Margulies, “Infant and Young Child Feeding: An Analysis of the WHO/UNICEF Meeting,” Studies in Family Planning 11, no. 2 (February 1980): 72–75. 39 WHO, International Code of Marketing of Breast-Milk Substitutes (Geneva: World Health Organization, 1981). 40 Edward Baer, “An Update on the Infant Formula Controversy,” Studies in Family Planning 14, no. 4 (April 1983): 119–22. 41 C. Jayaraj, “Why the US is Hostile Towards the UN System,” Social Scientist, 12, no. 5 (May 1984): 53–63. 42 WHO, The Selection of Essential Drugs: Report of a WHO Expert Committee, Technical Report Series WHO No. 615 (Geneva: WHO, 1977).

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43 Ibid. 44 Masuma Mamdami, “Early Initiatives in Essential Drugs Policy,” in Najmi Kanji, Anita Hardon, Jan W. Harnmeijer, Masuma Mamdami and Gill Walt, eds., Drugs Policy in Developing Countries (London: Zed Books, 1992): 1–23. 45 Jonathan Quick, Hans Hogerzeil, German Velasquez and Lembit Rago, “Twenty-ﬁve Years of Essential Medicines,” Bulletin of the World Health Organization 80, no. 11 (November 2002): 913–14. 46 As quoted in Richard Laing, Brenda Waning, Andy Gray, Nathan Ford and Ellen ‘t Hoen, “25 Years of the WHO Essential Medicines Lists: Progress and Challenges,” Lancet 361, no. 9370 (17 May 2003): 1726–27. 47 Sjaak van der Geest, “Anthropology and the Pharmaceutical Nexus,” Anthropological Quarterly 79, no. 2 (2006): 303–14; Mia Lydecker, Milton Silverman and Philip Randolph Lee, Bad Medicine: The Prescription Drug Industry in the Third World (Stanford: Stanford University Press, 1991), 48. 48 Laing, et al., “25 Years of the WHO Essential Medicines Lists: Progress and Challenges.” 49 Fiona Godlee, “WHO in Retreat: Is it Losing its Inﬂuence?” BMJ 309 (6967): 1491–95 (3 December 1994). 50 Vanessa Bradford Kerry and Kelley Lee, “TRIPS, the Doha Declaration and Paragraph 6 Decision: What are the Remaining Steps for Protecting Access to Medicines?” Globalization and Health 3, no. 3 (2007): 1–12. 51 William Steiger, Comments on the Recommendations Contained in the WHO Discussion Document “Updating and Disseminating the World Health Organization Model List of Essential Drugs: the way forward,” (Washington, D.C.: Department of Health and Human Services, 2001). 52 Sarah Boseley, “US Accused of Trying to Block Abortion Pills,” Guardian, 21 April 2005. 53 WHO, Report on the 12th Expert Committee on the Selection and Use of Essential Medicines (Geneva: World Health Organization, 2002). 54 Derek Yach and Stella Aguinaga Bialous, “Junking Science to Promote Tobacco,” American Journal of Public Health 91, no. 11 (November 2001): 1745–48. 55 Jeﬀ Collin, Kelley Lee and Karen Bissell, “The Framework Convention on Tobacco Control: The Politics of Global Health Governance,” Third World Quarterly 23, no. 2 (April 2002): 265–82. 56 Alec Irwin, Nicole Valentine, Chris Brown, Rene Loewenson, Orielle Solar, Hilary Brown, Theadora Koller and Jeanette Vega, “The Commission on the Social Determinants of Health: tackling the social roots of health inequities,” PLoS Medicine 3, no. 6 (June 2006): 749–51; Lee Jong-wook, “Public Health is a Social Issue,” Lancet 365, no. 9464 (19 March 2005): 1005–6. 57 WHO Commission on Social Determinants of Health, “About Us,” Geneva, 2005, www.who.int/social_determinants/about/en/ 58 Michael Marmot, “Health in an Unequal World,” Lancet 368, no. 9552 (9 December 2006): 2081–94; Richard Wilkinson and Michael Marmot, The Solid Facts, 2nd edition (Copenhagen: WHO Oﬃce for Europe, 2003). 59 Orielle Solar and Alec Irwin, “Social Determinants, Political Contexts and Civil Society Action: A Historical Perspective on the Commission on

Notes

60 61 62 63

141

Social Determinants of Health,” Health Promotion Journal of Australia 17, no. 3 (December 2006): 180–85. ILO, The Social Dimension of Globalization (Geneva: International Labour Organization, 2005). People’s Health Movement, “PHM’s Letter to Incoming WHO Director General Dr Margaret Chan,” 19 November 2006, www.phmovement.org/ en/node/296 Debabar Banerji, “Serious Crisis in the Practice of International Health by the World Health Organization: The Commission on Social Determinants of Health,” International Journal of Health Services 36, no. 4 (2006): 637–50. Ibid.

5 From international to global health 1 Anon, “World Health Organization,” International Organization 6, no. 4 (November 1952): 652–55. 2 Charles Ascher, “Current Problems in the World Health Organization’s Program,” International Organization 6, no. 1 (1952): 27–49. 3 Jason Finkle and Barbara Crane, “The World Health Organization and the Population Issue: Organizational Values in the United Nations,” Population and Development Review 2, no. 3/4 (September/December 1976): 367–93. 4 Javed Siddiqi, World Health and World Politics, The World Health Organization and the UN System (London: Hurst & Company, 1995). 5 Fiona Godlee, “The World Health Organisation: WHO in Crisis” BMJ 309, no. 6966 (26 November 1994): 1424–28. 6 Fiona Godlee, “WHO in Retreat: Is It Losing Its Inﬂuence?” BMJ 309, no. 6967 (3 December 1994): 1491–95. 7 Gill Walt, “WHO Under Stress: Implications for Health Policy,” Health Policy 24, (1993): 125–44. 8 Godlee, “The World Health Organisation: WHO in Crisis.” 9 J. Patrick Vaughan, Sigrun Mogedal, Stein-Erik Kruse, Kelley Lee, Gill Walt and Koen de Wilde, Cooperation for Health Development, Extrabudgetary Funds in the World Health Organization (London: Governments of Australia, Norway and the UK, 1995). 10 Gill Walt, “International Organizations in Health: The Problem of Leadership” in Pocantico Retreat, Enhancing the Performance of International Health Institutions (Cambridge, Mass.: Rockefeller Foundation, Social Science Research Council, Harvard School of Public Health, 1996): 23–37. 11 Julio Frenk, “The Future of World Health: The New World Order and International Health,” BMJ 314, no. (10 May 1997): 1404. 12 Kelley Lee, “Shaping the Future of Global Health Cooperation: Where Can We Go from Here?” Lancet 351, no. 9106 (12 March 1998): 899–902. 13 Jennifer Prah Ruger and Derek Yach, “Global Functions at the WHO,” BMJ 330, no. 7500 (14 May 2005): 1099–1100. 14 Richard Horton, “WHO’s Mandate: A Damaging Reinterpretation is Taking Place,” Lancet 360, no. 9338 (28 September 2003): 960–61. 15 As quoted in Michael McCarthy, “What’s Going on at the World Health Organization?” Lancet 360, no. 9340 (12 October 2002): 1108–10. 16 Gro Harlem Brundtland, “Address to WHO Staﬀ,” Geneva, 21 July 1998, www.who.int/director-general/speeches/1998/english/19980721_hq_staﬀ.html

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17 Godlee, “The World Health Organisation: WHO in Crisis.” 18 Steinar Andresen, Leadership Change in the World Health Organization: Potential for Increased Eﬀectiveness? (Lysaker, Norway: Fridtjof Nansens Institute, 2002). 19 Richard Smith, “The WHO: Change or Die,” BMJ 310, no. 6979 (4 March 1995): 543–44 20 Leonard Lerer and Richard Matzopolous, “‘The Worst of Both Worlds’: The Management Reform of the World Health Organization,” International Journal of Health Services 31, no. 2 (2001): 415–38. 21 Gavin Yamey, “WHO in 2002: Why Does the World Still Need WHO?” BMJ 325, no. 7375 (30 November 2002): 1294–98. 22 Kelley Lee and Kent Buse, “Assuming the Mantle: The Balancing Act Facing the New WHO Director-General,” Journal of the Royal Society of Medicine 99, no. 10 (October 2006): 494–96. 23 Gro Harlem Brundtland, “Our Common Future and Rio 10 years after: how far have we come and where should we be going?,” Address to World Business Council for Sustainable Development, Berlin, 4 November 1999, www.who.int/director-general/speeches/1999/english/19991104_berlin.html. 24 Gro Harlem Brundtland, “Presentation to the Development Assistance Committee of the OECD,” Paris, 9 November 2000, www.who.int/director-general/speeches/2000/english/20001109_paris.html 25 Gro Harlem Brundtland, “Luncheon, Washington International Business Council and Executive Council on Diplomacy,” Washington, D.C., 17 April 2001, www.who.int/director-general/speeches/2001/english/20010417_ IBCluncheonwashington.en.html 26 Gro Harlem Brundtland, “Health as Foreign Policy,” Ditchley Park, 26 April 2002, www.who.int/director-general/speeches/2002/english/20020426_ DitchleyParkOxfordshire.html 27 UK Department for International Development, Working in Partnership with the World Health Organization (London: HMSO, 2002). 28 Fiona Godlee, “The Regions – too Much Power, too Little Eﬀect,” BMJ 309, no. 6968 (10 December 1994): 1566–70. 29 Paul Benkimoun, “How Lee Jong-wook Changed WHO,” Lancet 367, no. 9525 (3 June 2006): 1806–8. 30 Sam Burcher, “Let Us Live and Let Them Die,” International Journal of Health Services 37, no. 4 (2007): 777–81. 31 Ernesto Sebrie and Stanton Glantz, “The Tobacco Industry in Developing Countries,” BMJ 332, no. 7537 (11 February 2006): 313–14. 32 Betsy McKay, “Three Top Jobs in Global Health Face Vacancies,” Wall Street Journal (5 September 2006). 33 Margaret Chan, “Address by Dr. Margaret Chan,” Executive Board, 120th Session, Geneva, 22 January 2007, www.who.int/dg/speeches/2007/ eb120_opening/en/index.html 34 Margaret Chan, “Message to all staﬀ from Director-General,” e-mail correspondence, 9 October 2007. 35 Kent Buse and Catherine Gwin, “World Health: The World Bank and Global Cooperation in Health: The Case of Bangladesh,” Lancet 351, no. 9103 (28 February 1998): 665–69. 36 Kamradt Abbasi, “The World Bank and World Health: Changing Sides,” BMJ 31, no. 7187 (27 March 1999): 865–69.

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37 Anne Mills, “Leopard or Chameleon? The Changing Character of International Health Economics,” Tropical Medicine and International Health 2, no. 10 (October 1997): 963–77. 38 David Werner, “Elusive Promise: Whatever Happened to Health for All?” New Internationalist 331 (January–February 2001). 39 As quoted in Gavin Yamey, “WHO in 2002: Have the Latest Reforms Reversed WHO’s Decline?” BMJ 325, no. 7372 (9 November 2002): 1107–12. 40 John Lister, Health Policy Reform: Driving the Wrong Way (London: Middlesex University Press, 2005). 41 Paula Braveman, Barbara Starﬁeld and H. Jack Geiger, “World Health Report 2000: How it Removes Equity from the Agenda for Public Health Monitoring and Policy,” BMJ 323, no. 7314 (22 September 2001): 678–81. 42 Vicente Navarro, “Assessment of the World Health Report 2000,” Lancet 356, no. 9241 (4 November 2000): 1598–1601. 43 Vicente Navarro, What is Happening at the World Health Organization? The Coming Election of the WHO Director-General, People’s Health Movement, 23 October 2006, www.phmovement.org/en/node/279 44 Philip Musgrove, “Judging Health Systems: Reﬂections on WHO’s Methods,” Lancet 361, no. 9371 (24 May 2003): 1817–20. 45 Gro Harlem Brundtland, “Address to Permanent Missions in Geneva,” WHO Headquarters, Geneva, 10 November 1998, www.who.int/directorgeneral/speeches/1998/english/19981110_missions.html 46 Howard Waitzkin, “Report of the WHO Commission on Macroeconomics and Health: A Summary and Critique,” Lancet 361, no. 9356 (8 February 2003): 523–26. 47 Kelley Lee, Alan Ingram, Karen Lock and Colin McInnes, “Bridging Health and Foreign Policy: The Role of Health Impact Assessment?” Bulletin of the World Health Organization 85, no. 3 (March 2007): 207–11. 48 Prabhat Jha and Frank Chaloupka, Curbing the Epidemic: Governments and the Economics of Tobacco Control (Washington, D.C.: World Bank, 1999). 48 Richard Horton, “The World Bank in Turmoil,” Lancet 369, no. 9572 (5 May 2007): 1492. 50 World Bank, Health Development: The World Bank Strategy for Health, Nutrition, and Population Results, World Bank, February 28, 2007. Prepared for meeting of the Committee on Development Eﬀectiveness, March 14, 2007. HNP strategy Annex A, 1, http://siteresources.worldbank. org/HEALTHNUTRITIONANDPOPULATION/Resources/281627–11540 48816360/HNPStrategyFINALApril302007.pdf 51 David McCoy, “The World Bank’s New Health Strategy: Reason for Alarm,” Lancet 369, no. 9572 (5 May 2007): 1499–1501. 52 Brundtland, “Address to WHO Staﬀ.” 53 Adrea Mach, “The New WHO Cabinet Looks Refreshingly Diﬀerent,” BMJ 317, no. 7157 (22 August 1998): 492. 54 WHO, WHO/Private sector talks, Press Release WHO/64 (Geneva: 1998), www.who.int/inf-pr-1998/en/pr98–64.html 55 Kent Buse and Gill Walt, “Global Public-Private Partnerships: Part I – A New Development in Health?” Bulletin of the World Health Organization 78, no. 4 (April 2000): 549–61.

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56 Derek Yach, “Injecting Greater Urgency into Global Tobacco Control,” Tobacco Control 14, no. 3 (2005): 145–8. 57 As quoted in J.L. Motchane, “Health for All or Riches for Some, WHO’s Responsible?” Le Monde Diplomatique (July 2002). 58 BBC News Online (21 July 1998). 59 Mach, “The New WHO Cabinet.” 60 Cheryl Scott, Chief Operating Oﬃcer, Gates Foundation, “Remarks prepared for Health Aﬀairs Summit,” Washington, DC, 1 November 2007, www.gatesfoundation.org/MediaCenter/Speeches/ExecutiveSpeeches/CSSpe echHealthAﬀairs071101.htm 61 Anne-Emanuelle Birn, “Gates’ Grandest Challenge: Transcending Technology as Public Health Ideology,” Lancet 366, no. 9483 (5 August 2005): 514–19. 62 Fiona Godlee, “Change at Last at WHO, But will the Regions Play Ball?” BMJ 317, no. 7154 (1 August 1998): 216. 63 Sarah Boseley, “Unhealthy Inﬂuence: There is a Danger That WHO’s New Partnership with Drug Companies will Skew its Health Policies,” Guardian (6 February 2002). 64 Duﬀ Wilson, “New Blood-pressure Guidelines Pay Oﬀ – for Drug Companies,” Seattle Times (26 June 2005). 65 Someshwar Singh, “TRIPS and the WHO’s Revised Drug Strategy,” Third World Network (19 May 1999), www.twnside.org.sg/title/drug-cn.htm 66 Anita Hardon, “New WHO Leader Should Aim for Equity and Confront Undue Commercial Inﬂuences,” Lancet 361, no. 9351 (4 January 2003): 6. 67 As quoted in Richard Horton, “WHO: The Casualties and Compromises of Renewal,” Lancet 359, no. 9317 (4 May 2002): 1605–11. 68 WHO, Guidelines for WHO Guidelines, Global Programme on Evidence for Health Policy (Geneva: March 2003), http://whqlibdoc.who.int/hq/ 2003/EIP_GPE_EQC_2003_1.pdf 69 Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases, Diet, nutrition and the prevention of chronic diseases, WHO Technical Report Series, No. 916 (TRS 916) (Geneva: 2003), www. who.int/dietphysicalactivity/publications/trs916/intro/en/index.html 70 WHO, WHO/FAO Release Independent Expert Report on Diet and Chronic Disease, www.who.int/mediacentre/news/releases/2003/pr20/en/. 71 Sugar Association, “About Us,” available at www.sugar.org/aboutus/ 72 “Nutritionists Unimpressed by Sugar Lobby’s Outcry,” Bulletin of the World Health Organization 81, no. 6 (June 2003): 469–70. 73 Michelle Simon, “Bush Supersizes Eﬀort to Weaken the World Health Organization,” International Journal of Health Services 35, no. 2 (2005): 405–7. 74 Sarah Boseley, “Political Context of the World Health Organization: Sugar Industry Threatens to Scupper the WHO,” International Journal of Health Services 33, no. 4 (2003): 831–33. 75 As quoted in Paul Benkimoun, “How Lee Jong-wook Changed WHO,” Lancet 367, no. 9525 (3 June 2006): 1806–8. 76 Benkimoun, “How Lee Jong-wook Changed WHO.” 77 Derek Yach as quoted in Michelle Simon, “Bush Supersizes Eﬀort to Weaken the World Health Organization.” 78 Derek Yach, “Food Companies and Nutrition for Better Health,” International Union of Nutritional Sciences, 2007, www.iuns.org/features.htm

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79 Gavin Yamey, “WHO in 2002: Faltering Steps Towards Partnerships,” BMJ 325, no. 7374 (23 November 2002): 1236–40. 80 “The Rights and Wrongs of WHO’s Policy of Censorship,” Lancet 360, no. 9350 (21 December 2002): 1995. 81 Dylan Williams, “World Health: A Lethal Dose of US Politics,” Asia Times (17 June 2006), www.atimes.com/atimes/Southeast_Asia/HF17Ae01 .html. 82 Michael Day, “Who’s Funding WHO?” BMJ 334, no. 7589 (17 February 2007): 338–40. 83 Gro Harlem Brundtland, Address to WHO Staﬀ, Geneva, 21 July 1998. www.who.int/director-general/speeches/1998/english/19980721_hq_ staﬀ.html. 84 UNAIDS, “The Essential Role of Civil Society,” in Global Report on AIDS 2006 (Geneva: 2006): 202. 85 Christophe Lanord, A Study of WHO’s Oﬃcial Relations System with Nongovernmental Organisations, Civil Society Initiative (Geneva: WHO, 2002), www.who.int/civilsociety/documents/en/study.pdf 86 WHO, Inventory of WHO/HQ Relationships with Nongovernmental Organisations (Geneva: Civil Society Initiative, February 2002), www. who.int/civilsociety/documents/en/inventory.pdf 87 WHO, WHO and Civil Society: Linking for Better Health (Geneva: Civil Society Initiative, 2002), www.who.int/civilsociety/documents/en/CSICase StudyE.pdf 88 Margaret Chan, “Presentation to the 119th Executive Board,” Geneva, 7 November 2006. http://www.who.int/dg/speeches/2006/eb_presentation/en/ index.html 89 Margaret Chan, Message from the Director General, World Health Day, May 2007. 90 International Health Partnership, “A global ‘Compact’ for achieving the Health Millennium Development Goals,” London, 5 September 2007. http://www.dﬁd.gov.uk/news/ﬁles/ihp/compact.pdf 91 Jorge Bermudez and Maria Auxiliadora Oliveira eds., Intellectual Property in the Context of the WTO TRIPS Agreement: Challenges for Public Health (Rio de Janiero: Oswaldo Cruz Foundation, 2004), www. law.fsu.edu/gpc2007/materials/LivroTRIPSEnglish2004.pdf 92 Germán Velásquez and Pascale Boulet, Globalization and Access to Drugs. Implications of the WTO/TRIPs Agreement, Health Economics and Drug Action Programme Series No. 7, Action Programme on Essential Drugs (Geneva: WHO, November 1997). 93 WHO, Draft Resolution on a Revised Drug Strategy, Resolution EB101. R24, WHA 51st Session, Geneva, 1998. 94 As quoted in Singh S. trips and the who’s revised drugs strategy. Third World Network, 19 May 1999, http://www.twnside.org.sg/title/drug-cn.htm 95 WHO, Second Report of Committee A, 52nd World Health Assembly, Draft Resolution A52/38, 24 May 1999, http://ftp.who.int/gb/archive/pdf_ ﬁles/wha52/ew38.pdf 96 Gro Harlem Brundtland, “WHO/WTO Workshop on Diﬀerential Pricing and Financing of Essential Drugs Opening Remarks,” Høsbjør, Norway, 8 April 2001, www.who.int/director-general/speeches/2001/english/20010408_ hosbjoropeningremarks.en.html

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97 WHO/WTO, WTO Agreements and Public Health: A Joint Study by the WHO and the WTO Secretariat (Geneva: 2002). 98 Nathan Ford and Jean-Michel Piédagnel, “WHO Must Continue its Work on Access to Medicines in Developing Countries,” Lancet 361, no. 9351 (4 January 2003): 3. 99 Martin Khor, “WHO DG Regrets her Reported Remarks on Thai Compulsory Licenses,” Third World Network, 13 February 2007, www. twnside.org.sg/title2/wto.info/twninfo503.htm 100 Ford and Piédagnel, “WHO must continue its work on access to medicines in developing countries.” 101 WHO, Health Aspects of Chemical and Biological Weapons, 1st edition (Geneva: 1970). 102 WHO, Public Health Response to Biological and Chemical Weapons: WHO Guidance (Geneva: 2004). 103 WHO, “World Health Organization Stresses Need for Continued Public Vigilance in Responding to Deliberate Infections,” Press Release, 18 October 2001. 104 Gro Harlem Brundtland, “Why Investing in Global Health is Good Politics,” Speech to the Council on Foreign Relations, New York, 6 December 1999, www.who.int/director-general/speeches/1999/english/1999 1206_new_york.html 105 Harley Feldbaum, Kelley Lee and Preeti Patel, “The National Security Implications of HIV/AIDS,” PLoS Medicine 3, no. 6 (June 2006): 774–78. 106 Margaret Chan, “World Health Day Debate on International Health Security,” News Release, Singapore, 2 April 2007, www.who.int/dg/speeches/ 2007/020407_whd2007/en/index.html 107 Charles S. Ascher, “Current Problems in the World Health Organization’s Program,” International Organization 6, no. 1 (February 1952): 27–50.

Select bibliography and electronic resources

Burci, Gian Luca and Claude-Henri Vignes, World Health Organization (The Hague: Kluwer Law International, 2004). The authors, as former and existing legal counsel to the WHO, provide a useful reference to the organization’s formal structure, mandate and constituencies based on a close reading of its Constitution and other oﬃcial documents. Fenner, Frank, Donald Ainslie Henderson, Isao Arita and Ivan Danilovich Ladnyi, Smallpox and its Eradication (Geneva: WHO, 1988). This substantial tome, a detailed account of the smallpox and malaria eradication programs, provides fascinating insights into how the initiatives were conceived and carried out with varying degrees of success. Garrett, Laurie, Betrayal of Trust: The Collapse of Global Public Health (Oxford: Oxford University Press, 2001). While this book is not ostensibly about the WHO, it reﬂects widespread concern about the worrying state of public health worldwide in the early twenty-ﬁrst century, and the failings of existing institutions to meet urgent needs. The book focuses especially on the interrelatedness of public health issues across national borders, and the need for strengthened international health cooperation. Koivusalo, Meri and Eeva Ollila, Making a Healthy World: Agencies, Actors and Policies in International Health (London: Zed Books, 1997). This book was written amid discussions about the reform of the WHO in the late 1990s as the ﬁrst book to provide a comprehensive account of the major institutions involved in international health cooperation. Along with the organization, ﬁnancing and activities of the WHO, it covers the World Bank, UNICEF, the UNFPA and the UNDP. Lee, Kelley, Historical Dictionary of the World Health Organization (Lanham, MD: Scarecrow Press, 1998). This is largely a reference text, containing entries on major aspects of the WHO’s structure, activities, membership and ﬁnancing, along with a brief introductory chapter on the organization’s history. Siddiqi, Javed, World Health and World Politics: The World Health Organization and the U.N. System (London: Hurst & Company, 1995). This is one of the few analyses of the political nature of decision making within the WHO, focused on malaria control but having wider relevance to understanding the history of the organization’s work and membership.

148

Select bibliography and electronic resources

Vaughan, J. Patrick, Sigrun Mogedal, Stein-Erik Kruse, Kelley Lee, Gill Walt and Koen de Wilde, Cooperation for Health Development: Extrabudgetary Funds in the World Health Organization (London: Governments of Australia, Norway and the UK, 1995). This report, known as Oslo I, was the ﬁrst detailed analysis of trends in WHO ﬁnancing from funds provided voluntarily to the organization, and the implications for priorities and activities pursued. WHO, The First Ten Years of the World Health Organization (Geneva: WHO, 1958). A useful text describing international health cooperation prior to the WHO’s founding, as well as the meetings and negotiations leading up to its creation in 1948. Electronic resources World Health Organization main website maintained in Arabic, Chinese, English, French, Russian and Spanish: www.who.int. The websites of the six regional oﬃces of the WHO are as follows: African Regional Oﬃce (Brazzaville) website is maintained in English and French: www.afro.who.int/ Americas Regional Oﬃce/Pan American Health Organization (Washington, D.C.) website is maintained in English and Spanish: www.paho.org Eastern Mediterranean Regional Oﬃce (Cairo) website is maintained in Arabic and English: www.emro.who.int/ European Regional Oﬃce (Copenhagen) website is maintained in English, French, German and Russian: www.euro.who.int/ Southeast Asian Regional Oﬃce (Delhi) website is maintained in English: www.searo.who.int/ Western Paciﬁc Regional Oﬃce (Manila) website is maintained in English: www.wpro.who.int/ Global Health Council, formerly the National Council of International Health, is a US-based non-proﬁt organization created in 1972 to identify priority world health problems and to report on them to the US public, legislators, international and domestic government agencies, academic institutions and the global health community. Its website oﬀers information on a wide range of global health issues: www.globalhealth.org/ UNAIDS, of which WHO is a co-sponsor, provides the most comprehensive information on the HIV/AIDS pandemic and international cooperation to address it: www.unaids.org. The trend towards open access publishing in public health has led to the free availability of peer-reviewed journals with articles relevant to global health. PLoS Medicine http://medicine.plosjournals.org/ Globalization and Health www.globalizationandhealth.com/

Index

Action Programme on Essential Drugs see essential medicines Ad Hoc Committee on Health Research 91; see also 10/90 gap Advisory Committee on Variola Virus Research 57 Afghanistan 69 African Regional Oﬃce 30, 33 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) 65, 92, 117, 122–24; TRIPS-plus 92; see also Declaration on the TRIPS Agreement and Public Health Aitken, Denis 105 Aldis, William 120 Alma Ata Conference see International Conference on Primary Health Care Alnick, David 51 American Regional Oﬃce see Pan American Health Organization Amorim, Celso 94 Annan, Koﬁ 52 anthrax 57, 125; see also bioterrorism anti-retroviral drugs and treatment 19, 63, 92; universal access to 64–65 Arab League 23 Argentina 5 Asamoah-Baah, Anarﬁ 51 Asher, Charles 100 assessed contributions see regular budget funds Australia 39, 43, 101, 103

Baker, James 24 Bangladesh 73, 90 basic needs approach 74, 97–98 Baum, Frances 96 Bégin, Monique 96 Berlinguer, Giovanni 96 Bern Third World Action Group 87 Bhagwan, Rajneesh 125 Bhore Commission 73 biomedical model 6, 9, 21, 70, 81, 96, 111: dominance within WHO 17, 101, 126–27; in family planning 100; use by industry 98 bioterrorism 57–58, 125 Black Death 1 Bolton, John 24 Botswana 116 Brazil 5, 7, 13, 28, 56, 91, 94; Oswaldo Cruz Foundation 91 Britain see United Kingdom broad determinants of health 6, 11, 70, 71–73, 81, 87, 96, 100, 126–27; deﬁnition 72; regulation of industry 89; see also Commission on the Social Determinants of Health, horizontal approach, vertical approach Brundtland, Gro Harlem 19, 50, 86; leadership style 104–5, 109; raising proﬁle of WHO 62, 85, 106–8, 114, 125; reform programme 29–30, 33, 42–44, 105–6; relationship with CSOs 121; relationship with private sector 115–21, 123–24; staﬀ appointments 105, 113; support for tobacco control 94–95, 98

150

Index

budget; balance between RBFs and EBFs 38–44, 106; budgeting cycle 41; constraints on 19–21, 24, 28–29, 43–44, 49, 55–56, 75, 84, 90–91, 124; Division of Budget and Finance 41; compared with World Bank 112; zero nominal growth 39, 98, 101, 106, 111; zero real growth 39, 98, 101, 111; see also regular budget funds, extrabudgetary funds Buﬀet, Warren 116 Burma 55 Bush, George 64, 66, 83, 93, 110, 119 Cambodia 55 Canada 15, 38, 43, 103 Candau, Marcolino 16, 27–29, 49 Chadwick, Sir Edwin 1, 6 Chagas disease 5, 92 Chan, Margaret 33, 97, 110–11, 121–22 charitable foundations 3, 11, 52, 116 Chatterjee, Mirai 96 Chen Shui-bian 23 Children’s Vaccine Initiative 67–70, 82 Chile 5, 87 China 13, 38, 43; as aid donor 115; barefoot doctors 73; handling of SARS outbreak 109; membership in UN 22–23 Chisholm, Brock 15–16, 27, 29, 100 cholera 2, 4–5, 14–15, 18, 81 Ciba-Geigy 116 civil society organizations 11, 75, 85, 87–88, 95, 108, 110, 120–23 Civil Society Initiative 121 Clinton, Bill 83 Cold War 9, 14, 24, 29, 34, 45, 125 collaborating centers 36–38 Colombia 5, 80 Commission on Health Research for Development 91 Commission on Intellectual Property Rights, Innovation and Public Health 124 Commission on Macroeconomics and Health 51–52, 97, 104, 114, 117; see also Sachs, Jeﬀrey

Commission on the Social Determinants of Health 72, 95–97; Department of Equity, Poverty and Social Determinants of Health 96 Committee on Administration, Finance and Legal Matters 26 Committee on Programme and Budget 26 Communism 9, 17 community-based health workers 73 compulsory licensing 92 conﬂicts of interest 117–18 Conseil supérieur de Santé de Constantinople 3 Conseil Sanitaire de l’Empire 3 Conseil Sanitaire de Tanger 3 Consumer Project on Technology 123 coordination 52–53, 61; for HIV/ AIDS 65 Country Cooperation Strategies 34–35 Country Focus Initiative 36 country oﬃces 34–36, 45, 103, 108, 127: WHO Representatives 33 see also Oslo I and II studies Crick, Francis 46 Cuba 4, 43, 73, 80 Dag Hammarskjold Foundation 103 Decision on the Interpretation of Paragraph 6 92, 124 Declaration of Geneva see Hippocratic Oath Declaration on the TRIPS Agreement and Public Health 92, 124 dengue 12 Denmark 43, 74 Dichloro-Diphenyl-Trichloroethane (DDT) 49–51 see also malaria Director-General 15–16, 19, 25, 27–29, 33, 38, 115; election process 84, 110–11; responsibilities of 41 diphtheria 2, 46, 48, 67, 80 disability-adjusted life years (DALYs) 113 Doha Declaration see Declaration on the TRIPS Agreement and Public Health Dominican Republic 42

Index Dracunculiasis; Global Programme to Eliminate 48 Drug Monitoring and Evaluation Programme 83 Drug Policies and Management Unit 83 drug resistance; antibiotics 91; HIV/ AIDS 91; tuberculosis 91 Drugs for Neglected Diseases Initiative (DNDI) 91–92 Eastern Mediterranean Regional Oﬃce 30 economism 111–15, 127; see also World Bank Ecuador 5 Egyptian Quarantine Board 3 Eisenhower, Dwight 39 El Salvador 5 encephalomyelitis 5 England 1 essential medicines 77, 83, 127; access to 75, 92, 122–24; Action Programme on Essential Drugs 90–91, 117, 122; Department of Essential Drugs 117; Expert Committee on the Selection and use of Essential Medicines 93; Model List of Essential Drugs/ Medicines 72, 89–94; Revised Drug Strategy 122 see also Agreement on Trade-Related Property Rights, Commission on Intellectual Property Rights, Innovation and Public Health Egypt 3, 69: cholera epidemic 14–15 European Commission for the Danube 3 European Community 23 European Regional Oﬃce 23, 30, 34, 68 Evidence and Information for Policy 113 Executive Board 31–32, 56, 123; composition 25–27, 44, 110; role in appointments 110 Expanded Programme for Technical Assistance 38 Expanded Programme on Immunization 48, 66, 80, 82

151

extrabudgetary funds 33, 38–44, 56, 59, 101–2, 106 Feachem, Richard 113 Finlay, Carlos 4 Foege, William 66, 85 Fogarty International Center 57 Ford Foundation 3 Framework Convention on Tobacco Control 72, 94–95, 109, 114, 118; Conference of the Parties to the FCTC 95; Framework Convention Alliance 95; Intergovernmental Negotiating Body 94; see also tobacco control France 13, 22, 38, 56, 83; Pasteur Institute 91 Frenk, Julio 102, 105, 110, 113 Fresle, Daphne 117 functionalism 10, 127 Gates Foundation, Bill and Melinda 116–17 Geneva Group 39 General Agreement on Trade in Services 124 Germany 14, 22, 38 Ghana 55 GlaxoSmithKline 116 Global Alliance for Vaccines and Immunization (GAVI) 116, 122 Global Forum for Health Research 91 Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis 52–54, 93, 110–11, 113–14; see also human immunodeﬁciency virus/ acquired immunodeﬁciency syndrome, malaria, tuberculosis global health: battle over deﬁnition of 99–100; shift from international to global health cooperation 11, 99–100 global health security 111, 124–27; Global Health Security Initiative 58 Global Malaria Programme see malaria Global Outbreak and Alert Response Network 22–23 Global Programme on AIDS 48, 59–62, 83; expansion of 59;

152

Index

Global Strategy for the Prevention and Control of AIDS 59 Global Programme on Evidence for Health Policy 117 Global Programme on Vaccines and Immunization 109 Global Programme to Eliminate Dracunculiasis see dracunculiasis Global Strategy on Diet, Physical Activity and Health 65, 118–19 globalization 11, 96–97, 99, 123 Globalization, Trade and Health Programme 124 Godlee, Fiona 100–101 Goodwill Ambassadors 81, 109 Grant, James 80–81 Grotjahn, Alfred 6 Group of Eight 52, 64, 114 Guatemala 88 Guerin, Jules 6 Guinea 55 Halstead, Scott 67–68 Harvard University 61, 102–3 health: broad deﬁnition of 9, 16, 76, 105 Health Action International 123 health equity see health inequalities health inequalities 79, 82, 85–86, 92, 96–97, 112–13, 121 Health for All 72, 74–75, 78, 82, 84–85, 87, 96, 98, 112, 127; Renewing the Strategy for 84 health care systems 115, 126; western-based model 73 Health Technology Cluster 116–17 healthy life expectancy (HALE) 113 Henderson, Donald 56–57, 66–67 Heymann, David 69 high politics 10 Hippocratic Oath 9 Holy See 21 horizontal approach 11, 75, 98, 100, 126; deﬁnition 47 see also vertical approach Horton, Richard 102, 110, 115 human immunodeﬁciency virus/ acquired immunodeﬁciency syndrome (HIV/AIDS) 19, 47, 70–71, 83, 85–86, 92–93, 110,

124–25; Alliance to Combat AIDS 60; AIDS Strategy for Africa 60; Consultation on Harmonization of International AIDS Funding 64; Control Programme on AIDS 58; Department of HIV/AIDS 64; funding for 63, 65; Global Task Team on improving coordination on HIV/AIDS 65; history of 58; Interagency Advisory Committee on AIDS 61; scaling up 116; Special Programme on AIDS 59; see also Global Programme on AIDS, Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis, Joint United Nations Programme on HIV/AIDS human rights approach 21, 24, 61, 79, 85, 121 India 14, 55, 57, 69, 73–74, 96, 124; Indian Council for Medical Research 91; plague outbreak 83 Indonesia 55 Industrial Revolution 1, 6 inﬂuenza 1–2, 12: avian inﬂuenza 109; pandemic 22, 125–26; Senior United Nations System Coordinator for Avian and Human Inﬂuenza 105; World Inﬂuenza Center 36 Interim Commission 14–15 International Code on the Marketing of Breast Milk Substitutes 72, 75, 87–89, 127–28; see also Bern Third World Action Group, Nestlé, War on Want International Committee of the Red Cross 24, 46, 74 International Conference of American States 4 International Conference on AIDS 58–59 see also human immunodeﬁciency virus/acquired immunodeﬁciency syndrome International Conference on Primary Health Care 75, 96; Declaration of Alma Ata 75, 76–79, 90

Index International Cooperation Year 56 International Federation of Pharmaceutical Manufacturers Association 123 see also pharmaceutical industry International Health Board see Rockefeller Foundation International Health Conference 13–14, 22, 27, 33 International Health Regulations 2, 17–18, 109, 126 International Hospitals Association 8 International Labour Organization (ILO) 7, 39, 62 International Monetary Fund (IMF) 82, 128 International Obesity Taskforce 118 International Sanitary Bureau see Pan American Sanitary Bureau International Sanitary Conferences 2, 4–5 International Sanitary Conventions 2, 18 International Sanitary Convention of the American Republics 4 International Sanitary Regulations 2, 17 International Telecommunication Union 23 International Union of American Republics see Organization of American States Iran 3 Iraq 55, 125 Israel 23–24, 30 Italy 38 James, Phillip 118 Jamison, Dean 102 Japan 1, 14, 16, 22, 27, 38, 83, 125; support for Oslo III 103 Johnson, Lyndon 56 Joint United Nations Programme on HIV/AIDS 48, 52, 62–66, 120; Global Health Sector Strategy for HIV/AIDS 62–63; Programme Coordinating Board 62 Kasten, Robert 24 Katz, Alison 110

153

Kazatchkine, Michel 53 Kenya; Medical Research Institute 91 Kern, Ann 105 Kim, Jim Yong Kochi, Arata 54 Korea 14, 22 Labouisse, Henry 75 League of Nations Health Organization 2, 4, 7, 14, 17, 27, 36, 46 League of Red Cross Societies 3, 8 Lee, Jong-wook 19, 65, 86, 95, 97, 109, 111, 121; reform of WHO 43, 110–11; handling of SARS outbreak 109; support for 3 by 5 initiative 63–64, 119 leishmaniasis 92 Leprosy Elimination Strategy 48 Liechtenstein 21 like-minded countries 101, 103 London School of Hygiene & Tropical Medicine 101–2 Lopez, Alan 105, 113 Love, James 123 low politics 10 see also high politics Lucas, Adetokunbo 102 Machel, Graca 104 Machel, Samora 104 Mahler, Halfdan 27, 58–59, 74–75, 83–84, 86, 97–98, 102; leadership style 100, 104; regulation of food industry 88, 98; support for essential drugs 90 malaria 3, 17, 56, 59, 70–71, 93, 117, 124; arteminisin-based combination therapies 51–54; funding for 49, 51–52; history of 47 ; Intensiﬁed Malaria Eradication Programme 39, 55, 100; Global Malaria Control Strategy 50; Global Malaria Eradication Programme 11, 28–29, 47–49, 53; Ministerial Conference on Malaria Control 50; resurgence 49–50; Roll Back Malaria 33, 50, 105, 120; see also Dichloro-Diphenyl-Trichloroethane Malaysia 91

154

Index

Mandela, Nelson 104 Mann, Jonathan 59–62, 83 Marmot, Michael 96–97 maternal and child health 17, 61, 77, 83 McNamara, Robert 80, 111 measles 48, 56, 67 Médicins sans Frontières (MSF) 91 Meeting of the Ministers of Foreign Aﬀairs of the American Republics 5 meningitis 5 mental health 16–17 Merck 116 Mexico 4–5; National Institute of Public Health 102 Millennium Development Goals (MDGs) 107; International Health Partnership – A “Global” Compact for Achieving the Health MDGs 122; Millennium Development Project 114 Mitrany, David 10 Morocco 3 Mozambique 80 Murray, Christopher 105, 113 Musgrove, Christopher 114 Nabarro, David 105, 115–16 Nader, Ralph 123 Nakajima, Hiroshi 27, 59–61, 68, 82–84, 86, 102; criticism of 83–84, 100, 105 neoliberalism 82, 84, 96, 111–14, 128 Nestlé 87–88 Netherlands 43 New International Economic Order (NIEO) 72, 76, 79 Newell, Kenneth 81 Nicaragua 5, 80 Niger 69 Nigeria 69 Niue and the Cook Islands 21 Non-Aligned Movement 72, 127 non-communicable diseases 118; Executive Director 119; Expert Group on Diet, Nutrition and the Prevention of Chronic Disease 118; see also Global Strategy on Diet, Nutrition and Physical Exercise

nongovernmental organizations 25, 30, 52, 62, 95, 115 see also civil society organizations normative activities 18–19, 21, 53, 103 Norway 39, 43, 101, 103; Centre for Partnership in Development 102 Nossal, Gustave 66 Novartis 117 Organization for Economic Cooperation and Development (OECD) 73; Development Assistance Committee 120 Oﬃce International d’Hygiène Publique 2, 4, 14, 17, 46 Onchocerciasis Control Programme 48 oral health 27–28 oral rehydration therapy 80–81 Organization of African Unity 50 Organization of American States 4 Oslo Group 34 Oslo I and II studies 40, 102–3 Pakistan 43, 55, 69 Palestine Liberation Organization 21, 23–24 Pan American Health Organization 14, 33, 45, 56 Pan American Sanitary Bureau 2, 4–5, 28, 33, 46, 49 Paraguay 5 People Living with AIDS 59 see also human immunodeﬁciency virus/ acquired immunodeﬁciency syndrome People’s Health Assembly 85, 96–97, 121 PepsiCo 119; Health and Wellness Advisory Board 119 pertussis 67, 80 Peru 7, 90 Pﬁzer 120 pharmaceutical industry 54, 87, 89–93, 98; protection of intellectual property rights 120, 122; role in FCTC 115; source of ﬁnancing 115–22 Philippines 73 Piot, Peter 62–63 plague 5, 18, 81, 83

Index Plague of Athens 1 poliomyelitis 5, 46–48, 66–69, 83; funding for 69; Global Polio Eradication Initiative 48, 67–68; International Commission for the Certiﬁcation of Polio Eradication 68; New Global Eradication Strategic Plan 69; oral polio vaccine 66–67, 69; transmission 66 politicization 11, 33, 39, 75, 81, 89, 100 Prequaliﬁcation Project 93–94, 124: Good Manufacturing Practices 93 see also essential medicines President’s Emergency Plan for AIDS Relief (PEPFAR) 64, 93 primary health care 75, 76–79, 85, 87, 98; funding for 80; comprehensive versus selective 80–82, 86, 96 Programme for Vaccine Development 66–68; Scientiﬁc Advisory Group of Experts 67 public-private partnerships 82, 92, 115–22 Puerto Rico 4, 21 quarantine 3, 18, 26 regional committee 31 regional director 31–33 regional oﬃces 30–34; variable capacity 44–45 regular budget funds 38–44, 56, 59; imbalance with EBFs 101; late payment of 42–43, 98 Reagan, Ronald 66 Reid, Elizabeth 60 relapsing fever 18 Rockefeller Foundation 28, 102, 116: Bellagio Conference Center 66–67, 80; International Health Board 3, 46; International Health Commission 3; International Health Division 3; Sanitary Commission for the Eradication of Hookworm Disease 3; support for social medicine 7; support for vaccine research 67–68 see also Children’s Vaccine Initiative

155

Roll Back Malaria see malaria Rosen, George 6 Rotary International 68 Sachs, Jeﬀrey 52, 97, 114 Salk, Jonas 80 Sand, René 7–8, 13 security see global health security Severe Acute Respiratory Syndrome (SARS) 23, 109, 125 sexually transmitted diseases 12, 17, 61 Sherry, Jim 67 Sholtz, Michael 116–17 smallpox 2, 5, 47, 54–58, 70: history of 54–55; Intensiﬁed Smallpox Eradication Programme 29, 39, 48, 56–57; Smallpox Eradication Programme 11, 28, 55, 66; stockpiling of vaccine 57–58 Snow, John 6 social medicine 11, 70–72, 96, 98: association with socialism 9, 14, 17; development as a discipline 6–8; inﬂuence over WHO’s Constitution 11, 17; Virchow’s principles 6 Somalia 42, 57 Soper, Fred 28, 49 South Africa; Medical Research Councuk 84 Southeast Asian Regional Oﬃce 30, 34, 120 Soviet Union 7, 9, 14, 38, 55: smallpox vaccination 55; virus samples 57; withdrawal from WHO 22, 55; Spain 4 Special Programme for Research and Training in Tropical Diseases 30, 91, 102 Sri Lanka 90 Stockholm Convention on Persistent Organic Pollutants 50–51 see also Dichloro-DiphenylTrichloroethane Stop TB Partnership see tuberculosis Store, Jonas Gahr 115 Sweden 43, 103 Sudan 69 Sugar Association 118–19

156

Index

Taiwan 22–23 Tanzania 73, 90 Technical Advisory Board see United Nations Special Fund Technical Preparatory Committee 13, 24 10/90 gap 91 tetanus 48, 67, 80 Thailand 65, 90, 120, 124 Third Way politics 115 3 by 5 Initiative 19, 63–65 Three Ones principles 64 Thompson, Tommy 58, 118 Thuillier, Jean 83 Titmuss, Richard 73 tobacco control 87, 101, 104; Tobacco Free Initiative 95, 105; World Conference on Tobacco or Health 109; see also Framework Convention on Tobacco Control Tokelau 21 trade policy 83, 122–24, 127; bilateral trade agreements 65, 92, 120; tensions with access to medicine 65, 92 tuberculosis 2, 17, 46, 48, 74, 81, 83, 93, 124: BCG vaccine 48, 67; global emergency 85; International Tuberculosis Campaign 48; links with HIV/ AIDS 85; multi-drug resistant 84–85, 91; Stop TB Partnership 30, 85; TB Alliance 85; Tuberculosis Unit 74 see also Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria Tutu, Desmond 104 typhoid 2, 46, 49 typhus 2, 5, 18 Uauy, Ricardo 118 United Kingdom 13, 22, 101; Department for International Development 105, 108; ﬁnancial contribution 38, 39–40, 43, 106; national health service 7 United Nations Children’s Fund 13, 19, 39, 50, 52, 56; basic needs approach 74; Convention on the Rights of the Child 81;

Declaration of Alma Ata 76–79; GOBI-FFF 80–82; involvement in polio eradication 66–67; involvement in UNAIDS 62–63; regulation of food industry 88–89; selective primary health care 80–82; shift from emergency relief 74; Task Force for Child Survival 66; rivalry with WHO 67–68, 81, 108; Working Group on AIDS 60–61; World Summit for Children 81 United Nations Conference on International Organization 13 United Nations Conference on Trade and Development 89, 104 United Nations Department of International Economic and Social Aﬀairs 61 United Nations Development Programme 19, 34, 38, 50, 66, 82; tensions with WHO 60–61 United Nations Economic and Social Council 13, 16 United Nations Educational, Scientiﬁc and Scientiﬁc Organization 39, 62, 89 United Nations General Assembly 16, 24; endorsement of malaria control 50, 52; sessions on HIV/ AIDS 52, 59, 64 United Nations High Commission for Refugees 62 United Nations Oﬃce on Drugs and Crime 62 United Nations Population Fund 60–62 United Nations Relief and Rehabilitation Administration 13–14 United Nations Special Fund 32, 38 United States 13, 22, 38, 113: Department of Health and Human Services 93; disease outbreak preparedness 57–58; disenchantment with UN 83, 101; dominance of biomedicine 9; establishment of schools of public health 3; ﬁnancial contribution 19–21, 24, 28–29, 42–44, 49, 54–56, 83, 90–91, 98; Food and

Index Drug Administration 93; membership in the League of Nations 2, 9, 17; opposition to industry regulation 88, 90–91, 118–19, 122; protection of PAHO 33; Public Health Service 4; tensions with Soviet Union 14, 57 United States Agency for International Development (USAID) 80 United States Centers for Disease Control 55, 58, 68 United States Institute of Medicine 66 United States National Institute of Allergy and Infectious Diseases 66 vertical approach 11, 62–64, 70, 75, 86, 98, 126; deﬁnition 47 see also horizontal approach Vietnam 22 Virchow, Rudolph 6–7 voluntary contributions see extrabudgetary contributions Walsh, Julia 80–82 Walt, Gill 102 War on Want 87 Warren, Kenneth 80–82 Washington Consensus 112 see also economism, neo-liberalism, World Bank Watson, James 46 Wellcome Trust 3 Werner, David 81 Western Paciﬁc Regional Oﬃce 30, 34, 68, 83 whooping cough 48 Working Group on Partnership in countries 34 World Bank 50, 52, 60–63, 66, 105, 111–15, 128; budget 84; essential package 82; Global Burden of Disease 82, 113; health strategy 115; rivalry with WHO 85, 108; role in health development 82, 111–12; structural adjustment programmes 82, 112–13; tobacco control 95; World Development Report 112

157

World Commission on Environment and Development 103; see also Brundtland, Gro Harlem World Commission on the Social Dimensions of Globalization 97 see also International Labour Organization World Food Programme 62 World Health Assembly 15, 17, 24–27, 29, 32, 49–50, 55; decision making process 110 World Health Day 15 World Health Organization (WHO): cluster structure 29–30, 105, 111, 115; Constitution 14–18, 21–22, 33–34, 71, 127; decentralized structure 24, 27, 30–34, 50, 127; establishment 1, 5, 9–10, 12–16; External Relations and Governing Bodies 115; functions 17, 20–21, 25–26, 103, 127; General Programme of Work 20, 25–26, 36, 41; leadership 46, 63, 84–85, 99–102, 105–6, 109–11; mandate 19–21, 27, 103; membership 21–24, 26, 127; pressure by donor countries 19; priority setting 27–29, 42–45, 84, 102, 106, 113, 127; reform process 29–30, 43–44, 101–3; Secretariat 27–30, 41, 88, 101, 123; technical activities 18–19, 21; World Health Report 113, 126 World Intellectual Property Organization (WIPO) 123 World Trade Organization (WTO) 92, 122–24, 128; WTO-plus 92; see also Agreement on TradeRelated Aspects of Intellectual Property Rights, Decision on the Interpretation of Paragraph 6 Wyman, Walter 4 Yach, Derek 84–85, 102,105, 109, 119 Yale University 7 yaws 5, 48 yellow fever 3–6, 18, 28, 49 Zaire 59 Zhdanov, Viktor 55