Managing Global Health Security

The World Health Organization and Disease Outbreak Control

A. Kamradt-Scott

• Publisher: Palgrave Macmillan
• Year: 2015
• Print ISBN:
  9780230369313
• eBook ISBN:
  9781137520166
• Topic: Social Sciences
• Subtopic: Medical Theory, Practice & Reference
• Index: Social Sciences

Drawing on insights from international organization and securitization theory, the author investigates the World Health Organization and how its approach to global health security has changed and adapted since its creation in 1948. He also examines the organization's prospects for managing global health security now and into the future.

1

The Legal Basis for the WHO’s Global Health Security Mandate and Authority

In 1946 when the WHO’s constitution was written, some 22 functions and duties were ascribed to the organization. Of these, the WHO’s chief function is the control and eradication of infectious diseases. Although often unspoken, the priority attached to this particular task is understandable when reviewing the historical origins of the WHO and the events of the immediate post-war period. The focus of this chapter is to outline the WHO’s delegated authority for eradicating infectious diseases, noting the terms and limitations of that authority, and the mechanisms by which member states have sought to exercise control over the IO to prevent agency slack. The chapter will also survey the historical origins of the WHO, with a particular focus on identifying the key ideas that both informed and shaped its creation and overall mandate. This chapter thereby establishes the foundation upon which the rest of the book is based, as it is only from an understanding of this delegated authority that we can, firstly, appreciate why so much importance has been assigned to this one central task, and secondly, understand why the organization’s approach to managing global health security has changed and adapted over time.

Said another way, the WHO has a legal obligation to its member states to assist them in responding to, controlling, and ideally eliminating infectious diseases. This obligation was established by what international law describes as a ‘delegation of powers’ from member states to an IO (Sarooshi 2005), and results in what PA theorists describe as a ‘delegation contract’ (Hawkins et al. 2006). As discussed in the Introduction, it was originally intended that the WHO would act as the directing and coordinating authority in all international health matters (and particularly in eradicating infectious diseases), actively guiding the international community’s efforts (Mackenzie 1950). Even so, the methods that the organization’s secretariat has used at times to pursue this mandate have attracted some controversy. For example, in the midst of the SARS-inspired global emergency in 2003, questions were raised over the extent of the IO’s role and authority (Rodier 2003). Some even suggested that the organization’s director-general and secretariat exceeded their authority, that they exercised ‘independent power’ (agency slack), and that in doing so the WHO’s bureaucracy had brought about a new era of ‘post-Westphalian’ health governance (Fidler 2004, Cortell and Peterson 2006). Questions were also raised in the aftermath of the 2009 H1N1 influenza pandemic, although attention then focused on the role that pharmaceutical companies had played in the director-general’s decision to declare a pandemic (Godlee 2010). While a number of internal and external investigations were launched to evaluate the WHO’s actions – with every investigation subsequently absolving the secretariat of any wrongdoing – it is evident that many of the policies and procedures the IO uses to pursue its health security mandate are not clearly understood. Where does the organization derive its authority? What is the extent of these powers? To fully appreciate this, we need first to examine the historical origins of the WHO.

The WHO’s historical origins and ethos

The creation of the WHO as a new intergovernmental organization dedicated to improving the world’s health reflected a particular worldview of the post-war period. This worldview held that IOs were an important mechanism for arranging international society to prevent further conflict. In this, the work of David Mitrany proved particularly influential in the closing months of the second, most destructive war humanity had ever known (Ashworth 2005, Fidler and Gostin 2008). Mitrany postulated that one of the principal causes of conflict was ‘the baffling division between the peoples of the world’ into nation-states, as they encouraged the emergence of nationalism, which served to divide rather than unite populations (Mitrany 1946, p. 5). To overcome this problem and thereby prevent further war, Mitrany advocated that international society needed to be re-arranged along functional lines and serviced by independent, apolitical, technical organizations. The central premise of his treatise was that the nation-state was redundant, as it was incapable of providing the requisite physical, social, and economic security to its citizens due to transnational forces beyond the control of any one government. Arguing that peoples’ loyalty to the state was integrally linked with the provision of services, Mitrany suggested that if IOs assumed these functions, then the citizens’ loyalty to the state would correspondingly shift. As the needs of populations were being met by IOs, people would increasingly see themselves less as citizens of individual countries and more as ‘citizens of the world’. Circumventing any concerns that he was advocating some form of Communist revolution, Mitrany also argued that this transition could be accomplished peacefully and incrementally: governments did not have to surrender their sovereignty, but rather progressively delegate responsibility for the provision of services to purpose-built IOs designed to meet specific social and economic needs. This functional approach to world order, the theory held, thus avoided the divisive competition for resources and the negative influence of politics, as peoples’ needs were met by functional, technical organizations.

Given the political climate of the post-World War II (WWII) period and his intimate involvement in post-war reconstruction efforts (Ashworth 1999), Mitrany’s functional approach to world politics garnered widespread support. The philosophical basis of Mitrany’s argument – that further conflict could be avoided through independent, apolitical IOs meeting peoples’ needs – appealed to many wearied by war. Functionalism, as Mitrany’s theory subsequently became known, came to be viewed as a legitimate political theory of International Organization and was heavily influential in the development of the UN and its specialized agencies such as the United Nations Educational, Scientific and Cultural Organization (UNESCO) and the WHO (Haas 1956, Siddiqi 1995). Moreover, although criticisms of this approach continue to emerge (Davis 2012), the philosophical underpinnings of functionalism – that the provision of certain services can be extricated from compromising political interference, thereby averting conflict – remains a guiding force in contemporary IO practice (Hale and Held 2012).

In the specific context of health, Mitrany’s proposal for technocratic, apolitical IOs to deliver specific services corresponded with two other developments that had been growing in popularity: the concept of health as a civil right and the rise of social medicine. The idea that health was every citizen’s entitlement and an obligation of the state had been gaining strength throughout the 19th century. Importantly, however, the primary focus of government-led initiatives during this period had been on preventing epidemics, and very few countries had instituted any widespread, state-sponsored programmes designed to improve overall population health. At the end of World War I (WWI) though, this situation changed dramatically as countries throughout Europe and the Americas instigated various initiatives to redress the massive loss of human life brought about by The Great War. Programmes focusing on eugenics as well as maternal and child health became standard, but expectations surrounding the role of the state in the provision of health and medical services did not ultimately come to the fore until towards the end of WWII (Porter 1999).

Likewise, although social medicine had its origins in the late 19th century, throughout the interwar years it had come to be increasingly recognized that factors such as housing, income, food quality, and the like had a discernible impact on population health and well-being. In contrast to clinical medicine – which focused on rectifying faults in the human body via surgical intervention or the burgeoning field of pharmacology – social medicine promoted the idea that achieving good health could only be realized by addressing the social and economic inequalities that contributed to ill health. The social medicine movement thereby adopted an explicit political agenda that both coincided with and argued in support of welfare provision and social security – themes that received considerable support in a post-war environment. As a concept and practice, social medicine then gained yet further support throughout the interwar years due to the fact that several of the world’s then-leading health experts – many of whom held prominent positions within governments and international institutions – actively endorsed its implementation (Porter 2006). Thus, despite the fact that the return of hostilities in 1939 impeded progress in advancing the social medicine agenda for a time, the foundations for the movement’s influence in future international health cooperation had nevertheless been laid.

Indeed, in the closing months of WWII addressing social and economic disparities and ensuring sufficient levels of social security were viewed with an additional level of significance. By 1945 it had come to be widely accepted that the reparations imposed on Germany by the Treaty of Versailles in 1919 had caused massive social and economic disruption, which in turn had generated significant discontent amongst the segment of Germany’s population that aided the rise of the Nazi regime to power (Lauterbach 1944, Klein 1948). For many involved in post-war reconstruction efforts, a clear link therefore existed between social welfare provision and international security. Health and access to healthcare services subsequently came to be viewed as integral to not only ensuring domestic stability but also to enabling international peace and security. Health was viewed as a means to peace and was seen as just one area in which technical cooperation (such as that championed by Mitrany’s functional approach) could flourish.

It is in this regard that the connections between health, international security, and the WHO can be traced back to the origins of the organization. From its very founding, a strong correlation existed between the idea that international security was attained and maintained by ensuring good health, and it was expected that governments would cooperate to protect the peace that had been so hard won. Having said this, the correlations between health and security as conceived in the immediate post-war period contrasts significantly with the health-security nexus of the 21st century. Whereas post-WWII good health was deemed essential to maintaining peace and security – resulting in the outlook of health-for-security – by the turn of the new millennium (and as subsequent chapters go on to explore), the focus had inverted, so that health had become synonymous with security – or health-as-security.

The decision taken in 1946 to create a new, universal health agency epitomized the functional approach to world politics, but also reflected dissatisfaction with the existing intergovernmental institutions responsible for the control of infectious disease.1 The adverse effect that disease outbreaks could have on international trade (and thereby on national economic interests) had long been recognized by governments. In the 14th century the city-state of Venice was the first to institute a system of quarantine designed to protect its inhabitants from diseases aboard ships travelling along international trade routes. Within a matter of years, other European authorities instituted their own versions of quarantine, but significant inconsistencies existed between them, due in large part to differing beliefs about how diseases spread (Porter 1999). In an attempt to limit the negative impact that varying quarantine practices were having on international trade, the first International Sanitary Conference was convened in Paris in 1851. The conference lasted a full six months, and although the delegates of the 12 countries in attendance agreed to a set of regulations comprising 137 articles, all except two governments failed to ratify the agreement (WHO 1958).2 Between 1851 and 1938, a further 15 conferences and meetings were convened (often in direct response to an epidemic that was then sweeping throughout Europe) in an attempt to overcome the differences between countries. Yet while authorities failed in their objective of developing a consistent system of measures, the repeated epidemics of cholera, plague, typhoid, and yellow fever, amongst other diseases, emphasized the need for greater international coordination and cooperation (Goodman 1952).

Accordingly, in 1907 the Office Internationale d’Hygiene Publique (OIHP) was founded in Paris, France, by the League of Red Cross Societies to monitor the emergence and spread of disease outbreaks. One of the key tasks assigned to the OIHP was to gather and interpret epidemiological data, which it would then publish in a weekly journal. Yet while the OIHP performed its duties perfunctorily, the organization was widely perceived as being concerned exclusively with affairs that affected Europe – a perception aided by the fact the IO only ever published its findings in the French language. It thus emerged that following the creation of the League of Nations at the end of WWI, in 1922 a decision was taken to establish a health division of the League that would adopt a wider focus in addressing the widespread famine and disease that had emerged in the aftermath of the war. The League of Nations Health Organization (LNHO) was created the following year (LNHO 1931). Yet while the LNHO engendered greater support than its parent organization, like the League it failed to secure North American participation and was thereby unable to claim universal membership. Rather than stimulate cooperation, however, the relationship between the OIHP and LNHO became marred by controversy and competition (Howard-Jones 1978). Added to this, various regional organizations such as the Pan American Sanitary Organization (PASO) (which later was renamed the Pan American Health Organization [PAHO] in 1958) and the Pan Arab Regional Health Bureau further complicated the jurisdictional boundaries. In 1943, fearing a repeat of the various epidemics that arose at the end of WWI, the international health sphere became even further complicated by the creation of the United Nations Relief and Rehabilitation Administration (UNRRA), which was built specifically to help liberated populations recover and rebuild as soon as possible. Addressing health needs, including preventing disease outbreaks, epidemics, and pandemics, was a core focus of the UNRRA’s work (Goodman 1952). As a result of this complex environment, by the end of WWII there was broad agreement that the existing institutions should be subsumed within a new universal agency – a new world health organization – to ensure more effective international cooperation (Sharp 1947).

Given this history, it is understandable that several of these prevailing ideas and beliefs would inform the development of the WHO. Reflecting the contemporary view that health was a civil right, for example, the preamble of the new IO’s constitution explicitly declared that ‘enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’ (Preamble, WHO Constitution – WHO 2005a, p. 1). Evidencing the conviction that the provision of social welfare was integral to ensuring a conflict-free world, the constitution was drafted to note that the health ‘of all peoples is fundamental to the attainment of peace and security’ (ibid.). Finally, exemplifying the broader principles of social medicine, the Constitution specified that health was defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ and that ‘Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures’ (ibid.).

To facilitate the merger of multiple organizations into a single entity, the Interim Commission of the World Health Organization was formed in 1946 to oversee the transition. It took almost a full two years before the requisite 26th member state ratified the WHO Constitution on 7 April 1948, officially establishing the new IO. As one commentator later recorded though, ‘For all practical purposes, and despite this dilatoriness of governments . . . WHO had existed since 1946’ (Calder 1958, p. 5). Indeed, the Commission immediately set about adopting the work of the OIHP, the UNRRA, and the now largely defunct LNHO in gathering epidemiological intelligence and responding to disease-related emergencies while also initiating negotiations with the PASO to integrate the regional organization within the WHO. These discussions took the better part of three years to conclude before the PASO became the WHO’s regional office for the Americas on 1 July 1949 (WHO 1958).

Importantly, however, the negotiations surrounding the integration of the PASO also had a wider effect in determining the overall structure and operation of the new WHO. The International Sanitary Bureau had been originally established in 1902 by the US government to help overcome ‘the complicated mosaic of differing quarantine, inspection, and exclusion regulations that impeded the movement of goods’ throughout the Americas (Fee and Brown 2002, p. 1888). The Bureau, which was renamed the Pan American Sanitary Bureau (PASB) in 1923, then joined with the Pan American Sanitary Conferences in 1947 to become the PASO. Critically, throughout its existence the organization had retained an explicit regional focus on the Americas – a focus that the leaders of the PASB/PASO were reluctant to surrender. Accordingly, when the proposal to create a single new universal health agency was made in 1946, the PASB campaigned fiercely to retain its independence from the WHO (Lee 2009). Eventually, a compromise deal was struck in 1949 that permitted the now PASO to become the WHO’s regional office for the Americas, with autonomy over its own budget and programme of work (Sharp 1947, Fee and Brown 2002, Burci and Vignes 2004). The precedent established by the PASO, however, permitted other regions to argue for equivalent arrangements, with the result that by 1951 some six regional offices had been created – the Americas, the Western Pacific, South-East Asia, the Middle East, Europe, and Africa – overseen by a central headquarters based in Geneva, Switzerland. This arrangement has subsequently led some to argue that there is not one WHO but rather seven organizations (six regional offices and a central headquarters), which contrib...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright
• Dedication
• Contents
• List of Table
• Acknowledgements
• List of Acronyms
• Introduction
• 1 The Legal Basis for the WHO’s Global Health Security Mandate and Authority
• 2 The WHO’s Classical Approach to Disease Eradication
• 3 Securitization and SARS: A New Framing?
• 4 New Powers for a New Age? Revising and Updating the IHR
• 5 Pandemic Influenza: ‘The Most Feared Security Threat’
• 6 Global Health Security and Its Discontents
• Concluding Remarks
• Notes
• Bibliography
• Index