The Rockefeller Foundation, Public Health and International Diplomacy, 1920–1945

Josep L Barona

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9781848935679
• eBook ISBN: 9781317316770
• Edition: 1
• Topic: History
• Subtopic: World History
• Index: History

Based on extensive archival research, this study examines the role of the Rockefeller Foundation and the League of Nations in improving public health during the interwar period. Barona argues that the Foundation applied a model of business efficiency to its ideology of spreading good health, creating a revolution in public health practice.

1
International Diplomacy Meets Public Health

Scientific knowledge on health is spatially situated and not something disembodied and universal. Therefore, in its production and orientation it is closely linked to the economic system and political interest.¹ It is essential to conceive science and medicine as it is made, negotiated, received and reshaped in a range of sites.² In the first half of the twentieth century geopolitical reasons led to a cultural and scientific hegemony, whereby social elites shaped a system of values justifying the colonial domination of the Western powers.³ The history of international health cooperation started with the joining of forces to control communicable diseases.⁴ The first initiatives and agreements on health matters among national authorities were prompted by the need of measures to protect trade to prevent the spread of pestilence – particularly cholera, plague and yellow fever.⁵ Therefore, since the central decades of the nineteenth century, health occupied a relevant place in the international agenda.⁶ The birth of an international sanitary movement became a reference to local policies facing the scientific and social dimensions of health and disease. It influenced the production of medical knowledge, a series of aspects of clinical practice, public health policies and campaigns, prevention and national initiatives for the health care organization in urban and rural districts.⁷

International diplomacy was the clue agent which played a prominent role in this process of international negotiation. The increasingly widespread political concern about the negative effects of health impairment over social stability also influenced the birth of an international scientific community around hygiene, endowed with a growing importance in the different domains, based on new forms of political and scientific legitimacy: negotiations of medical standards, the creation of national laboratories, institutes and schools of public health, sanitary campaigns, expert committees and international conferences, technical reports and sanitary interventions. The most practical uses of science and public policies were linked to the growing prestige of the expert qualification as a fundamental tool for political authorities and practical intervention.⁸

During the second half of the nineteenth century, the main sites of experimental medicine and laboratory research were research institutes, usually attached to universities, as well as national agencies that were founded in most European countries, among others, the Pasteur Institute in Paris, the Institute of Hygiene and Tropical Medicine in London, the Robert Koch Institute in Berlin, the State Institute of Health in Copenhagen and other similar ones in Madrid, Zagreb, Warsaw and Prague. These research centres were the venue of scientists around the world, particularly in the European context. Young scientists began their experimental research in fields such as physiology, serology, bacteriology or pharmacology following research programs in a widespread network.⁹

Although the scientific importance of these research institutes did not decrease during the first decades of the twentieth century, after the end of the First World War the internationalization of medical science and the increasing political and commercial importance of agreements on public health were influenced by two international organizations whose power and influence were unprecedented. The first was the Rockefeller Foundation and more particularly its International Health Board, which signed agreements with many national authorities regarding public health campaigns and designed an efficient grantees policy aiming at creating an extensive network of well-connected public health professionals.¹⁰ The other key actor was the Health Organization of the League of Nations, which prompted an ambitious international health program by creating expert commissions, promoting international conferences, exchanging programs and experiences, promoting research in certain fields and funding health campaigns. They gave a strong impulse to vital statistics and a series of public domains such as nutrition, drug consumption, rural hygiene, standardization of diets, biological products and pharmaceuticals, maternal and child health, among others. The strategy of improving the health standards of the European population was an essential part of the international stabilization policies in a time of huge social tensions and deep conflicts.

Epidemics and Trade

Surveillance and control of epidemics were historical precedents of international intervention on health matters during the first half of the nineteenth century.¹¹ Maritime transport was the principal factor of plague transmission and local health committees used to apply isolation measures, quarantines and sanitary cordons. A system of clean and dirty patents had been introduced among national authorities to allow or restrict navigation depending on political interests and on the epidemic situation of the city of origin.¹² After the terrible plague that affected Marseille, in 1720, quarantine measures got more rigid in maritime stations, involving retention of the ship during a quarantine period, disinfection of goods and the medical inspection of passengers.¹³ This international system of patents and the quarantine stations represent the oldest trace of international health based on a model whose main goal was preserving cities and borders from plague contagion.¹⁴ The traditional quarantine system was closely linked to the colonial hegemony of Western powers, as a means to maintain their privileged position. A wide historiography has analyzed the role of hygiene and public health politics in the dynamics of colonialism.¹⁵

Feeling threatened by those national discretionary measures, several European states raised the need for international health regulations to address the spread of pandemics, with minimum damage of trade. Diplomatic contacts between governments culminated with the celebration of a dozen International Sanitary Conferences, whose main result was the cooperation for the establishment and implementation of rules aimed at controlling infectious diseases.¹⁶

The Paris Conference (1851) was not the first attempt to convene international agreements on public health measures, since a long process of diplomatic action had been doing so since the early nineteenth century.¹⁷

To promote international agreements on quarantine regulation, the pressure of the foreign policy of the colonial powers has traditionally been considered as a key factor, mainly France and Britain, to avoid dangerous protectionist policies that could harm their commercial interests. The rise of international trade during the first decades of the nineteenth century and the commercial interests of the colonial powers were the main support to the birth of an international diplomacy for public health policies. As a matter of fact, the Sanitary Conferences were openly conceived as a political and commercial tool.

The emergence of Asian cholera, a disease seldom affecting the European societies before the beginning of the nineteenth century, appeared as a fearsome pandemic, added to the traditional epidemics, generating confusion at a crucial stage for colonial interests and the expansion of a world trade market. By the mid-nineteenth century maritime trade had increased fivefold compared to the beginning of the century. The quarantine system and other restrictive measures, implemented by the states around public health, had become a political and diplomatic tool for the fight between rival powers. In addition, epidemics were a risk for the health of the population, for social stability and for the sanitary control of ports and borders. Indeed, the Vienna Conference (1815) opened a new stage of negotiation between representatives of countries, in which international conflicts became a matter of diplomacy and negotiation rather than of war and weapons.¹⁸

A series of international conferences on health and demography, children’s protection, tuberculosis, milk depots and venereal diseases, among others, gave way to discussions involving experts and national authorities, and international agreements on specific issues, which were apparently much more effective to fight the spread of diseases and to settle national and international policies to cope with them. In this context the international sanitary conferences were agreed as a locus of an intense diplomacy, whose interest extended beyond strictly health matters.¹⁹

The establishment of quarantine to prevent the spread of epidemics and regulate trade from contaminated sites was an ancient practice that had been established in many Mediterranean countries since the mid-fifteenth century. Cities traditionally had local government bodies to prevent the spread of epidemics using quarantines and sanitary cordons. After the early 1830s the preventive measures against cholera usually applied to goods and passengers coming from the Eastern countries as this was the origin attributed to the cholera plague, but they were also implemented to ships from the West Indies to prevent the spread of yellow fever. The traditional policy of quarantines and sanitary cordons was still in force at the start of the nineteenth century. Nevertheless the quarantine stations went through critical moments not only for political and commercial grounds, but also for public health arguments. Although political measures should be taken to prevent epidemics, health officers and health authorities started to discuss its usefulness. Companies associated with the import and export of products put pressure to avoid obstacles to normal trade. Sanitary cor-dons along land borders were even more ineffective due to fraudulent schemes of traders trying to circumvent the law to not harm their business. This controversial situation encouraged conflicts and debates, and reinforced the idea that the key issue was to establish an effective system of reporting epidemic outbreaks rather than implementing isolation and quarantine schemes. But the establishment of an effective system of recording and reporting epidemiological records required methodological agreements and a hard international coordination to ensure that the reports issued by the ports of origin were trustful and homologable, and were not handled according to pure political, military or commercial interests.

This plurality of factors made the problem of epidemics enter into the agenda of international diplomacy since the end of the eighteenth century, at a time when the pressure from big trade companies against quarantines and sanitary cordons was increasing. Moreover, economic liberalism boosted international sanitary conferences to alleviate the tendency to state protectionism.²⁰

The criticism against quarantines also incorporated scientific arguments against the new doctrine of microbe contagion that justified its application, associating the origin of the disease to the environmental conditions of the endemic place where the epidemics originated. The opinion of many doctors was critical to the effectiveness of quarantine and to some arguments of the colonial medicine. As a consequence, a series of studies on the conditions of occurrence of communicable diseases was carried out to highlight the importance of sanitary and environmental local conditions apparently contributing to transform endemic into epidemic diseases, in certain regions.²¹

Under those controversial circumstances, the explosive emergence of cholera in Europe during the 1830s highly impaired the international sense of risk and impotence against new hazards. Since the sense of vulnerability increased among the Europeans, quarantine emerged as a means of trying to isolate the infectious focus, and hence to spoil the only possible mechanism of prevention. However, the lack of certainty about the causes and mechanisms of disease transmission and the controversial diversity of opinions about routes of infection leftno room for further medical and political action.

The first initiatives aiming to propose an international regulation of quarantine occurred in Louis Philippe’s liberal France as an attempt to modify the previous Bourbon protectionism. As early as 1817, F. E. Fodéré advocated convening an international conference to promote agreements and regulations to end the chaos represented by the plurality of national quarantine legislations, their lack of effectiveness and the interfering commercial relations.²² Some years later, Nicolas Chervin (1833) raised the issue again in similar terms.²³

The growing international concern about epidemics and the controversy on quarantines opened the doors to international diplomacy. In 1834, the physician M. De Ségur-Dupeyron was commissioned by the French Ministry of Commerce to prepare a report on the various ways of implementing the quarantine system in Mediterranean ports. He made personal visits to main harbours, studied their way of implementing quarantines and reported his conclusions to the French minister.²⁴ De Ségur-Dupeyron established a link between trade and epidemics observing that there were no cases of epidemics in war areas where trade had been disrupted. He believed that preventive measures were necessary, but were ineffective as applied and therefore recommended the establishment of a uniform system of preventive measures, ranging from short-term quarantine until its abolition in the case of ships sailing from the Western Indies. That strategy obviously required international agreements and, despite the existence of an adverse climate for cooperation, in 1838 the French government assumed the hosting of an international conference gathering together representatives of European countries with ports in the Mediterranean Sea to negotiate a common system of quarantine and public health control of maritime routes and borders. The proposal received support from two of the largest northern European powers: Great Britain, involved in large commercial interests in the Mediterranean in transit to the Middle East and India, and Austria, affected by numerous quarantine stations on both riverbanks of the Danube and its borders with the Ottoman Empire. Participant powers aimed to generate international regulations, whereas international conferences could alleviate the difficulties of international diplomacy and move towards a peaceful resolution of political and commercial problems with a hygienic background.

De Ségur-Dupeyron’s report also influenced decisions affecting other Mediterranean areas of French colonies. In 1836 a meeting was held in Tangier, attended by Dupeyron himself, which served to convene in April 1840 to all consuls of foreign states in Tangier at a meeting that was the starting point of the creation of a Conseil Sanitaire Maritime International in the city. The strategy of surveillance and regulation led by France, Britain and Austria was spread to other southern Mediterranean areas such as Libya, Egypt, the Ottoman Empire and, therefore, similar international health councils were created in Tunisia (1835), Constantinople (1839), Alexandria (1843) and Tripoli, which claimed some coordination and control over these strategic areas.

Although the 1848 revolution disrupted the work done in favour of international agreements around quarantine, France returned to the idea of holding an International Sanitary Conference, which finally took place in Paris (1851–2). Until the creation of the Office Internationale d’Hygiène Publique (1907) and the League of Nations Health Organization, a long series of international conferences on sanitary matters took place in Europe; those events becoming the most relevant open forum to discuss and negotiate international health regulations. Negotiations and agreements implied not only foreign policy, but also certain scientific concepts under debate.²⁵

The first international sanitary conference took place in Paris ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• Acknowledgements
• List of Tables
• Abbreviations
• A Note on Principal Characters
• Introduction
• 1 International Diplomacy Meets Public Health
• 2 The First Great Intervention: Epidemics and Famine in Eastern Europe
• 3 The Extension of the Collaborative Programme
• 4 International Health and the End of the League of Nations: Gautier’s Evaluation
• 5 Some General Conclusions
• Appendix 1: International Sanitary Conferences, Commissions and Boards, Previous to the League of Nations (1920)
• Appendix 2: Health Scheme of the League of Nations for the Establishment of a Permanent International Health Section
• Appendix 3: Agreement between the League of Nations Health Organization and the International Health Board of the Rockefeller Foundation
• Works Cited
• Notes
• Index