Global Health Governance

Jeremy Youde

• Publisher: Polity
• Year: 2013
• ISBN:
  9780745660981
• Edition: 1
• Topic: Política y relaciones internacionales
• Subtopic: Globalización

In recent years the spread of diseases such as AIDS, SARS and avian flu has pushed health issues towards the top of the international agenda. Such outbreaks have serious political, economic, and social consequences and remind the world of the necessity of global cooperation in order to deal effectively with the challenges they pose.

Global Health Governance offers a comprehensive introduction to the changing international legal environment, the governmental and non-governmental actors involved with health issues, and the current regime's ability to adapt to new crises. Part 1 focuses on the evolution of international regulations aimed at stopping the spread of health problems across borders. Over the last 150 years, the nature of such cooperation, the motivations of the parties involved, and the diseases covered, has changed radically. Part 2 examines some of the most prominent actors in global health governance today, ranging from traditional intergovernmental organizations, such as the WHO and the World Bank, to private philanthropic organizations that exist outside regular global governance structures. Part 3 concentrates on some of the most pressing issues facing global health governance today, including access to pharmaceuticals, the costs and benefits of making health a security issue, and the role of civil society organizations.

Global Health Governance provides an accessible and insightful analysis of an evolving realm of global governance and cooperation. It will appeal to students of global health politics, global governance, international organization, and human security.

PART I
History

CHAPTER ONE

Early International Health Governance Efforts

Protecting trade, rather than improving health, drove early international health governance efforts. Diseases cross borders. They can disrupt trade, as states want to avoid importing new, exotic diseases from foreign countries. Such commercial worries inspired most of the impulses toward international cooperation on health issues from the mid-nineteenth century through World War II. Governments sought to work together because they did not want commerce interrupted, but they also wanted to ensure that disease prevention measures were not so stringent that they would impede international business.

This economic motivation significantly shaped the international health cooperation structures that developed before World War II. It oriented the system toward a dominant focus on a few commercially relevant diseases. Instead of taking steps to promote good health in a holistic sense, the system emphasized a more defensive stance against importation. It initially relied more on quarantines and bills of health instead of implementing health promotion programs or providing technical assistance to governments.

In the aftermath of World War I, shifts began to take place within health cooperation strategies. New actors, like the Health Organization of the League of Nations (HOLN) and the Rockefeller Foundation (RF), emerged with new outlooks. They encouraged cooperation among states on health issues, promoted the exchange of health information, and saw the relevance of implementing health promotion programs. These new actors challenged the existing thinking about health cooperation, but the conflict between paradigms led to much confusion.

This chapter examines the evolution of international cooperation on health matters from the mid-nineteenth century, when the first formal cooperative efforts began, through World War II. I start by discussing the International Sanitary Conferences and the eventual creation of the International Sanitary Regulations (ISR). At the start of the twentieth century, the first international organizations dedicated to health matters emerged – the International Sanitary Bureau (ISB, the forerunner of today’s Pan American Health Organization) and the International Office of Public Hygiene (known by its French acronym, OIHP). The last section of this chapter examines the emergence of new forms of international health cooperation and the difficulties in fostering cooperation among its organizations during the interwar period.

The International Sanitary Conferences and Convention

Fear of cholera prompted the first serious coordinated efforts at creating a system of international public health governance. Not only did cholera kill quickly, but its spread tended to mirror trade routes. The illness spreads via a bacterium, Vibrio cholerae, through infected food, water, or bodily waste. Symptoms appear rapidly and include a bloated feeling in the abdomen, generally with no accompanying fever, that quickly gives way to very watery stool. The disease can cause severe dehydration and kidney failure, leading to death in as few as 18 hours. Without treatment, mortality rates range from 50 to 90 percent. Its lethality has made cholera one of the most feared diseases throughout history. In the early 1800s, before cholera itself reached Europe, reports from British colonial officials about cholera’s effects in India terrified government officials and the general public alike. British Army officials reported losing 10,000 troops to cholera in India between 1817 and 1827, and McNeill estimates that upwards of one million Indians perished from cholera during this time (McNeill 1998: 269).

Cholera first reached Europe around 1829 during the second global cholera epidemic, spreading east to west along shipping traffic routes. It appeared in Poland in 1830 and 1831 before expanding to London and Paris in 1832. Over 6,000 Londoners died of cholera that first year, and Paris lost approximately 7,000 of its 650,000 residents (Rosenberg 1987). As the disease continued to spread throughout Europe between 1829 and 1847, tens of thousands of people lost their lives.

To prevent cholera’s spread, governments initially relied on quarantines of goods and peoples from infected regions. Quarantine is perhaps the oldest form of trying to prevent the spread of infectious diseases, with evidence for its use going back to biblical times. Chapter 13 of Leviticus describes how certain skin ailments like leprosy make a person “unclean.” When the priest finds someone with an infectious skin condition, he must cast that person out. Leviticus 13: 45–46 explains, “The person with such an infectious disease must wear torn clothes, let his hair be unkempt, cover the lower part of his face, and cry out, ‘Unclean! Unclean!’ As long as he has the infection, he remains unclean. He must live alone; he must live outside the camp.” The authorities exile the infected to prevent the disease’s spread.

Systemized quarantine began in the fourteenth century as a way to combat bubonic plague. In 1377, the Republic of Ragusa, a small republic centered on modern-day Dubrovnik along the Adriatic coast, introduced the first-ever organized quarantine procedures. By order of the Rector, ships coming from ports known to have or suspected of having bubonic plague were required to drop anchor away from the port for 30 days. If disease did not emerge during this time, then the ship could enter the port proper, and commerce could go forward as normal (Frati 2000). Land travelers were eventually added to the decree, and the isolation period was increased to 40 days, giving rise to the term quarantine (from quarantena, or “40-day period,” in Italian).¹ Ragusan officials saw quarantine as vital for protecting the “quality and safety of the trade network” (Gensini et al. 2004: 258).

Over time, quarantine procedures expanded to include more diseases, including cholera. Despite their popularity, quarantine policies were of questionable benefit. Goodman calls successful applications of quarantine “largely fortuitous” and highlights the fact that “in any case, not only were these measures of quarantine generally useless, but they were exasperating, obstructive, oppressive, and often cruel to the point of barbarity” (Goodman 1971: 34). Police would arrest anyone who looked “suspicious” of carrying cholera, forcing them into squalid, isolated hospitals (Tesh 1987: 12). Aside from the human costs, quarantines undermined the growing commercial ties developing in Europe during the mid-1800s. They slowed down shipments, added costs, and were applied inconsistently. There existed little to no coordination among governments as to how and when to implement quarantine restrictions.

Peoples and governments feared cholera, but they also bemoaned the impediments to trade and travel that quarantines imposed. This combination prompted the first calls for international coordination for addressing a public health issue.

What governments found most irksome were the often disastrous hindrances to international commerce, and it was this concern that finally prompted the European nations to meet to discuss to what extent these onerous restrictions could be lifted without undue risk to the health of their populations. If, in the old colonial days, it was true that “trade follows the flag,” it was equally true that the first faltering steps towards international health cooperation followed trade. (Howard-Jones 1975: 9–11)

Calls for an international conference on cholera control emerged as early as 1834, but it was not until 1851 that 12 European governments agreed to meet in Paris. Conference participants initially endeavored to regulate the use of quarantines in a uniform manner and to discuss the feasibility of establishing an international sanitary board to oversee maritime activities (Goodman 1971: 42–3). This first conference eventually produced a convention with 11 Articles and 137 Regulations covering cholera, plague, yellow fever, and other diseases “reputed to be importable” (Goodman 1971: 46). In the end, though, only three governments eventually ratified the convention – and two of those states, Portugal and Sardinia, later withdrew their ratification in the face of logistical difficulties in implementing the regulations (McFadden 1995: 82). In essence, no one ended up agreeing to abide by the agreement.

What prevented agreement during these initial efforts toward international cooperation on a public health issue? All parties recognized the dangers of cholera and the usefulness of coordinating prevention measures, so it would seemingly have been in all parties’ interest to come to agreement. This did not prevent the emergence and persistence of significant disagreements. Some of the disputes arose from commercial and geographic interests. Nations with significant trading interests showed strong resistance to any quarantine measures, since they impeded the free flow of goods. Countries bordering the Mediterranean Sea and the Ottoman Empire tended to favor quarantine, as they perceived cholera coming from the east or by sea and felt themselves in greater danger from its arrival (McFadden 1995: 80).

Disagreements also persisted over cholera’s cause and spread. It is hard to agree how to contain a disease when the parties cannot even agree what they are trying to contain. Three theories dominated, each with its own policy recommendations. One camp subscribed to the miasma theory. Its adherents believed that weather, climate, and “pestilent air” gave rise to environmental conditions that caused cholera (Tesh 1987: 25–32). According to this theory, quarantine made little sense because cholera’s origins were environmental. The miasmists instead called for improved sanitation and environmental conditions as the key to alleviating cholera. Since this theory saw no role for quarantine and other trade impediments, it appealed to the most trade-dependent states. British officials were particularly forceful advocates of this theory, recommending the abolition of quarantines and the “substitution of sanitary regulations” instead (Goodman 1971: 46).

The second theory, contagion theory, argued that cholera was transmitted from person to person via an infectious agent (Tesh 1987: 11–16). If cholera were communicable, then quarantines could potentially prevent the disease from entering a country by separating the infected from the healthy. In practice, government officials often used quarantine to justify discriminatory policies. They would round up and detain disfavored groups, particularly Jews and foreigners, in quarantine, but rationalize their actions by appealing to public health needs (Tesh 1987: 13). Spanish, Greek, Tuscan, and Russian delegates played a key role at the first conference in promoting this view and advocating for quarantine’s positive benefits (McFadden 1995: 82).

The third theory about cholera’s spread was supernatural. Illness was a sign of God’s displeasure, and transgressing God’s law provoked His wrath in the form of a highly fatal disease. Churches would hold special prayer services, encouraging worshippers to repent their sins and ask to be spared from the ravages of cholera (Tesh 1987: 17–21). This position gave little role for quarantine, as that would have little effect so long as God remained displeased. The head of the Austrian delegation went even further, arguing that cholera epidemics benefited society. Widespread illness and death would punish the “dregs of society” and encourage survivors to recommit themselves to a more pious life, he argued (Howard-Jones 1975: 13–15).

These competing theories about cholera’s origin and spread prevented European governments from coming to agreement about the appropriate steps to take to prevent cholera – or whether they even should take such measures. Over the next 40 years, five more conferences were held – 1859 in Paris, 1866 in Constantinople, 1874 in Vienna, 1881 in Washington, and 1885 in Rome – but none produced any substantive agreement.

Successful efforts at crafting an international agreement on infectious disease control began at 1892’s International Sanitary Conference in Venice. Robert Koch’s work on cholera helped forge a scientific consensus on cholera’s cause, spread, and treatment. The resultant agreement, the International Sanitary Convention (ISC), was extremely limited in scope. It allowed only for limited quarantine measures and medical inspections for ships passing through the Suez Canal going to and from Mecca for the annual hajj (Howard-Jones 1975: 45). Despite its narrow focus, the ISC helped launch efforts toward international coordination and cooperation on infectious disease control. As Howard-Jones acknowledges, “That such a declaration [on the cause of cholera] should have been generally accepted and that the conference resulted in the first International Sanitary Convention are landmarks in the history of international cooperation in matters of public health” (1975: 64). The following year, in 1893 at a conference in Paris, the assembled states expanded the limited 1892 agreement to cover movement by land and allowed greater use of medical inspections. A subsequent revision in 1897 added plague to the list of reportable diseases subject to the Convention (McCarthy 2002: 1111). Over time, the ISC was expanded to include diseases such as yellow fever, smallpox, typhus, and relapsing fever (Fidler 2005: 330).

The International Sanitary Convention of 1892, and its subsequent revisions over the next 58 years, focused its efforts on protecting states against the spread of infectious disease while minimizing interference with international trade and travel. Indeed, the Convention’s Preamble stated that the signatory states had “decided to establish common measures for protecting public health during cholera epidemics without uselessly obstructing commercial transactions and passenger traffic” (Fidler 2005: 329; emphasis added). To achieve these goals, the ISC called on states to notify one another about outbreaks of specific diseases and to establish and maintain adequate public health capabilities at ports of entry and exit, such as seaports and airports. The ISC also limited the measures that states could impose to prevent the importation of infectious disease, establishing the ISC’s rules as the most stringent regulations allowable under international law (Fidler 2005: 329). This clause sought to ensure that states would not impose overly burdensome regulations that could impede trade. States may not have wanted diseases within their borders, but they really did not want to stop the flow of goods across borders.

Early International Health Organizations

When initially adopted, the ISC lacked a formalized mechanism or organizational structure for coordinating the Convention’s surveillance and reporting requirements. The absence of a central international health organization hampered communications and made surveillance difficult. During the first decade of the twentieth century, two organizations emerged to help fill a coordinating role. In 1902, the International Sanitary Bureau (ISB; later the Pan American Sanitary Bureau, and today known as the Pan American Health Organization) was established to implement the ISC in the Americas. Five years later, European states created the Office International d’Hygiène Publique (OIHP) to fulfill a similar role (Gostin 2004: 2623). While in many ways complementary, the two organizations did not specifically coordinate their activities or share their resources with each other. Their foci protected individual state sovereignty instead of focusing on the larger global efforts to implement infectious disease control (Gostin 2004: 2623–4).

International Sanitary Bureau (ISB)

The mishmash of quarantine regulations in the Americas impeded trade in the hemisphere and hampered the United States’ business interests. Rules and inspection regimes varied widely throughout the region, limiting the easy movement of goods and frustrating economic expansion (Wegman 1977). To resolve these difficulties, the delegates to the Second International Conference of the American States in 1901 charged the Governing Board of the International Union of American Republics to call a convention to establish sanitary regulations that would harmonize and minimize quarantine restrictions throughout the region. The delegates also requested the creation of the International Sanitary Bureau to oversee and implement such regulations (Howard-Jones 1981: 7). The convention met in December 1902. It approved the ISB’s creation, giving it a mandate to receive reports on the sanitary conditions of ports and territories throughout the Americas. While the convention created the ISB, it did not initially provide the bureau with any resources. The ISB had no staff, no facilities, and a minuscule budget. Instead, it relied upon the United States Public Health Service for its operations and even employed the US Surgeon-General as the ISB Chairman (Fee and Brown 2002: 1888).

The ISB’s creation established an important milestone. For the first time, national governments came together to create an international organization with some measure of regulatory capability explicitly for health-related reasons. Health was not incidental to the ISB, nor was it a late addition to an existing organization’s mandate. The ISB’s creation also offered a significant innovation for international sanitary agreements. While some of the earlier International Sanitary Conferences resulted in agreements among the attendees, none of them had effective enforcement mechanisms. They relied primarily on moral suasion to ensure that members complied and interpreted the mandates of the agreements in the same way. By creating an organization, the International Sanitary Bureau demonstrated the practicability of enforcing and interpreting sanitary standards in a manner that would avoid impeding commerce unnecessarily.

International Office of Public Hygiene (Office International d’Hygiène Publique)

Like the ISB, the International Office of Public Hygiene (Office International d’Hygiène Publique, or OIHP) emerged out of an international agreement on sanitary regulations and sought to oversee quarantine regulations. While the OIHP lacked a specific regional mandate, it focused its attention on protecting European states.

At the 1903 International Sanitary Conference in Paris, the assembled delegates decided to combine the various agreements made at previous conferences into a single document. The resulting regulations, the International Sanitary Regulations (ISR), focused on cholera and plague; yellow fever received a fleeting mention. The ISR also mandated an international health office in Paris. Four years later, with the signing of the Rome Arrangements on December 9, 1907, the OIHP came into being with a small permanent staff and provisional headquarters – though it occupied those facilities until the organization’s dissolution 40 years later (Howard-Jones 1978: 7). The OIHP’s mandate was threefold: administering the International Sanitary Regulations; maintaining an epidemiological intelligence service; and collecting health data from member-states (World Health Organization n.d. b). Though the International Sanitary Regulations only applied to cholera and plague in 1903, the OIHP’s epidemiological surveillance operations collected data on a wider range of infectious diseases including malaria, hookworm, and tuberculosis. It also kept an eye on the Middle East because member-states feared that Muslim pilgrims to Medina and Mecca could transmit disease outbreaks to Europe (Zacher and Keefe 2008: 34).

In its operation and outlook, the OIHP clung to a mission of protecting Europe from the importation of “foreign” diseases while ensuring minimal inconvenience for international trade. By one calculation, 71 percent of ISR rules focused primarily on Africa, Asia, and the Middle East (Fidler 1999: 19). This narrow focus undermined the organization’s efficacy, instead of its being a robust presence. Howard-Jones described the OIHP’s outlook in less-than-glowing terms:

Fundamentally, it [the OIHP] was a club of senior public health administrators, mostly European, whose main preoccupation was to protect their countries from the importation of exotic disease without imposing too drastic restrictions on international commerce. (Howard-Jones 1978: 17)

The OIHP focused on limiting the spread of disease at borders, not by addressing the underlying causes of disease. Further limiting cooperation, states were slow to ratify the International Sanitary Regulations. By the time World War I broke out, nearly a decade after the treaty’s creation, only ...