The World Health Organization (WHO)

Kelley Lee

• Publisher: Routledge
• Year: 2008
• Print ISBN: 9780415370172
• eBook ISBN: 9781134199884
• Topic: Politics & International Relations
• Subtopic: Peace & Global Development
• Index: Politics & International Relations

The World Health Organization (WHO), as the United Nations specialized agency for health, has been at the centre of international health cooperation for over sixty years. With origins dating from the nineteenth century, 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. WHO has enjoyed many high-profile successes such as the global eradication of smallpox and 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 has brought the organization into contact with issues such as globalization, poverty, social justice and human rights.

Kelley Lee analyzes the WHO's role in international cooperation, examining its changing structures, key programmes and individuals. Of particular focus are the challenges WHO has faced in recent years given the emergence of other global health initiatives and how WHO has sought to remain effective as the "world's health conscience" within an increasingly complex global context.

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 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.

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 twenty-sixth 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 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 Director-General 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.

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 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 disease-focused 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 consolidation of the recommendations of the preceding 13 International Sanitary Conven...

Table of contents

• Routledge Global Institutions
• Contents
• Illustrations
• Foreword
• Acknowledgments
• Abbreviations
• Introduction
• 1 Creation of the World Health Organization
• 2 Structure and functions
• 3 Global campaigns against disease
• 4 Tackling the broad determinants of health
• 5 From international to global health
• Notes
• Select bibliography and electronic resources
• Index