World Health Organization and global health governance

By the end of World War II, countries arrived at a mutual understanding that "the health of all nations is the foundation for peace and security and relies on cooperation at the individual and national level” (WHO, 1946, p. 1). To achieve "the attainment by all peoples of the highest possible health” (WHO, 1946, p. 2), WHO was established to build on the progress brought by the International Sanitary Convention. A specialised agency of the United Nations, WHO acts as the directing and co-ordinating authority on international health work and has played an important role in the formulation and implementation of global health policies. The founding of the organisation is a landmark in the history of global health governance.

Background of the World Health Organization

The Constitution of the World Health Organization, adopted at the International Health Conference in 1946, marked the official establishment of WHO. The Constitution is the fruit of century-long public health diplomacies. Its establishment officially marked the institutionalisation of global health cooperation. Events that led to the creation of WHO roughly fall into the following stages.

Early International Sanitary’ Conferences (1851-1897)

A crucial observation characterising the international spread of disease is that “it follows the path of human transportation” (Siegfried, 1965, p. 16). Maritime transport grew rapidly in the middle of the 19th century with total tonnage of maritime transport in the world surging from 700,000 tons in 1850 to 2.62 million tons in 1910 (Headlick, 1981, p. 167). The Suez Canal opened in 1869, significantly raising the amount of goods transported, cutting costs and providing opportunities for Western travellers, Muslim pilgrims and migrants looking for better working and living conditions. Between 1815 and 1915, 46 million people had left Europe for different parts of the world, mainly North America. In the 19th century, 50 million people left China and India to settle in Latin America, Africa and various island territories (Headrick, 1988, p. 26). Accompanying the rising flow of people and goods was the settlement of serious diseases (such as malaria and cholera) in their new homes.

European countries dominated international commerce at the time, contributing 70% of the world’s total trade volume. A major trading country, the United Kingdom alone took up 20% (Foreman-Peck, 1983, p. 3). Yet despite the high volume of goods traded between Europeans and North Americans, the fastest growing international trade routes were between Europe and Asia. The volume of international travel to and from Asia, with its own share of indigenous contagious diseases, made international public health a major policy agenda in Europe. Rather than “disease importing countries” in southern Europe and the Middle East, the mam initiators of public health cooperation in the mid-19th century were industrialised countries with significant maritime interests concerned with the delay of shipments from “quarantines”.1 Fidler (1999) holds that the main purpose of developing multilateral health cooperation in the 19th century was to protect “civilised” countries, mostly European ones, from being tainted by “uncivilised”—in particular Eastern—countries (p. 28). In other words, the initial international health cooperation among European countries was not intended to improve the state of international health but to protect their own economic interests and whose main priority was preventing the spread of diseases originating in Asia, Africa and Latin America.

Prior to 1851, nation states took three main measures to cope with the spread of disease. The first was through prayer and sacrificial offerings. A lack of scientific understanding for epidemiology made people regard an epidemic as a form of divine retribution to which no other response than prayer and sacrifices would suffice. The second approach was to isolate healthy people from unhealthy people through the practice of cordon sanitaire to prevent either an importation or exportation of disease. The thud was to set up quarantine policies under which goods and people coming from areas suspected of having an outbreak would be isolated to reduce the risk from contracting diseases. For example, the Italian port of Ragusa in 1377 demanded all people from areas affected by the plague to stay at a designated place outside the port for 40 days. During the 14th and 15th centuries, many European countries had taken some type of mandatory quarantine measures, targeting ships, crews, passengers and cargo from foreign ports believed to be places prone to epidemic outbreaks, especially to plagues, yellow fever and cholera. Yet the differences in the mechanisms adopted had unintentionally strangled the flow of people and goods. An Italian government memorandum described this state of segregation as “anarchy through and through” (Goodman, 1971, p. 65). Disorganised policies such as these also found their way into contemporaneous literary works.2

In the following centuries, it became increasingly common to place infected people in quarantine along the Mediterranean coast. But such practice impeded the flow of goods and people between countries, leading to international conflicts. Quarantine policies then became dependent on cooperation between countries to be effective. European countries, prompted by a cholera scourge in 1830 causing thousands of deaths and widespread panic, decided to set up an international public health regime to cope with the spread of infectious diseases, hr 1851, at France’s initiative, the first International Sanitary Conference convened in Paris,

WHO and global health governance 57 opening the history of international public health cooperation. The purpose of the conference was to coordmate and resolve inconsistent and costly maritime quarantine policies of different countries in Europe, especially those with ports along the Mediterranean coast. Austria, France, Great Britain, Greece, Portugal. Russia, Spain, Turkey and four sovereign states that later united into Italy (the Papal States, Sardinia and the two Sicilies), attended the meeting. Most participants wanted to reach an agreement to standardise quarantine policies aimed at preventing cholera, plague and yellow fever. However, partly due to the lack of solid scientific evidence of the aetiology of the disease, partly because major shipping countries held their maritime commercial interests as a more urgent priority, countries had difficulty achieving consensus on specific texts of the International Sanitary Convention. In particular, they found it hard to standardise policies that were detrimental to international trade and transportation aimed at containing the transnational spread of disease.3 Eventually, the motion to coordinate quarantine measures due to various inherent and insurmountable difficulties did not pass. Members of delegations, many of whom were physicians and diplomats, were equally baffled for their lack of pathogenic knowledge and ignorance on the transmission modes of the pathogens. Their ignorance of the disease manifested in renewed debate on whether the disease was caused by “miasma” or by “contagion”. Miasmatists believed the disease was caused by the local duty and foul air, whereas contagiomsts believed it was directly transmitted from infected people to healthy people. The views held by each country' firmed out to be closely aligned with their own economic interests. “Miasma theory” was in Britain’s interest. As the leading maritime power at the time, the United Kingdom held that cholera was not a contagious disease; therefore, no quarantine or international management measures would help contain the disease. France seconded this view as the country benefited from merchant ships that sailed throxrgh the Suez under French jurisdiction. Quarantines, whether at the national or international level, were bound to harm French's shipping interests. At the meeting, Britain strongly opposed the provision granting countries the right to enforce quarantines. Countries along the Mediterranean and Black Sea coasts, on the other hand, supported port authority’s right to quarantine. Unable to strike a compromise between public health and maritime and commercial interests, the participant countries had not one who ended up ratifying the draft International Sanitary Convention.

A second International Sanitary Conference was held in Paris in 1859, repeating the fate of the previous meeting. Dismissing quarantine measures as useless, the United Kingdom even more vehemently denied the use of quarantine policies. The Ottoman Empire and Greece, however, insisted they had the right to enforce quarantines on ships and personnel travelling their ports. The resulting draft treaty, which took five months to develop, looked identical to the previous one in 1851. Little was accomplished.

In 1864, a fourth cholera epidemic broke out in India and soon spread to other-regions, lasting until 1872. After pilgrims who contracted cholera in Hejaz (the provincial name of the present Saudi Ar abia) returned to the Ottoman Empire and Egypt, they brought devastating consequences to these places. In response, at the initiative of the Ottoman Empire. Britain. Fi ance, Russia and other countries held the third International Sanitary Conference. Although all participants agreed the cholera originated in India and was transmitted to other countries through infected travellers, Britain still maintained that cholera would not spread from person to person. Of the 21 countries represented at the conference, Britain, Russia, the Ottoman Empire and Persia all voiced oppositions to quarantines with varied motivation. Britain and Russia worried that then merchant ships passing through the Black Sea might be affected, did not want to compromise their commercial interests. The other two countries were more concerned about the liigli medical expenses they would have to bear if quarantine measures were to be implemented at their own ports. In summary, conflicts of interest, especially among bigger countries, made it virtually impossible for any collective action in international public health cooperation to take place. The fifth International Sanitaiy Conference, held in Washington in 1881, in turn reflected the conflict of interest between the United States and the rest. The agenda concerned ways to control yellow fever, but the central point of contention was not about members’ rights to impose quarantine restrictions or sanitaiy inspections on passing ships but rather about the request from the United States to allow its own consuls, as opposed to local authorities, to issue a Bill of Health to ships destined for the United States. This requirement of extraterritoriality was met with strong opposition from other countries, especially from Latin America. The subsequent sixth Conference, held in Rome in 1885, and the seventh Conference, held in Venice in 1892, once again demonstrated the Anglo-French commercial rivalry. France, claiming that cholera was transmitted from British India, particularly Mumbai, to Europe wanted to impose more stringent sanitaiy measures on ships crossing the Suez Canal of the Red Sea en route to the West. France had profited handsomely from these ships, of which four-fifths were British. In 1884 alone, as many as 770 ships passed the canal sailing for British ports from India. Taking advantage of this fact, the British threatened to divert their shipping away from the French-run Suez Canal to force France to make concessions. Javed Siddiqi (1995) observed. “Persian and Turkish sensitivities were offended by the claim that cholera was endemic within then-borders and considered any calls for tougher quarantines of ships leaving from Persian and Turkish ports an infringement of their sovereignty” (p. 17). Conflict of interest stymied any progress achieved through such conferences.

By the end of the 19th century, European countries held several more International Sanitaiy Conferences. In the course of nearly half a century, Europe’s effort to coordmate public health policies resulted in frequent conclusions and replacements of conventions on infectious disease control, a process known as “a flurry of international conventions” (Carvalho & Zacher, 2001. p. 240). (see Table 3.1). Most of the cooperation were failures rather than successes. Only one international convention (targeting cholera) went into effect in 1892, the first and the only substantive outcome out of seven international conferences held in a span of 41 years. All these international conferences focused only on cholera, more specifically on the sanitaiy control of ships sailing westwards through the Suez Canal, most of which were British. Continental Europe was deeply concerned that

Table 3.1 International Sanitary Conferences Between 1851 and 1897

Year

Venue

Initiator

Result

1851

Paris

France

The fir st International Sanitary Convention is signed.

1859

Paris

France

The convention to simplify’ the first International Sanitary Convention is adopted.

1865

Paris

Ottoman Empire

Discussions on maritime quarantine measures are held.

1874

Vienna

Russia

A convention to set up an international standing committee on infectious diseases is adopted.

1881

Washington D.C.

United States

A convention to set up an international health regime is adopted.

1885

Rome

United Kingdom

Discussions on quarantine measures related to cholera control are held.

1887

Brazil

United Kingdom

An international quarantine convention is adopted.

1892

Venice

France

The 1892 International Sanitary Convention is adopted.

1897

Venice

Austria-Hungary

The 1897 International Sanitary

Convention is adopted.

the Suez Canal might become a path for cholera to spread from India to Europe. “History has proved that these concerns were groundless” (Howard-Jones, 1975, p. 65). In 1874, the fourth International Sanitary Conference adopted a convention to set up an international standing committee on infectious diseases but had no follow-up policies. In essence, most of the International Sanitary Conferences in the 19th century were mere formalities and not institutionalised hi any way. It is true that ignorance concerning infectious diseases may have held countries back from reaching consensus; the more fundamental reason, though, had to do with their primary occupation with business interests rather than public health concerns. The deep-rooted conflicts of interest between countries made it difficult to reach a common ground in the negotiations of global health conventions. Notwithstanding this sequence of events.

From the point of view of practical results, the first International Sanitary' Conference was a fiasco. Everyone went on doing in their own way what they had done before. Yet there was more to it than that. The fact that the conference took place established the principle that health protection was a propersubject for international consultations even though international health cooperation was for many years to be limited to defensive quarantine measures. The French Government of the time had planted a seed that was not to germinate for some forty years and then, after a complicated cycle of development, to blossom more than half a century later into WHO.

(Howard-Jones, 1975, p. 16)

3.1.2 Institutionalisation of international health cooperation

By the end of the 19th century. European countries gradually realised that international conventions and treaties alone could neither address common vulnerabilities nor “put an end” to the threat of infectious diseases. Global health governance required formal regimes through which they could implement and enforce the international conventions. The institutionalisation of global health governance went through three important stages.

Stage 1 : Establishment of the Office international d’hygiène publique (OIHP) (1903-1938). At the beginning of the 20th century, international public health cooperation picked up the pace. On the one hand, although conventions reached in the 19th century had been ratified by some countries, regulations and rules on international public health issues remained vague, and then enforcement was a controversial topic. Most countries did not comply with existing regulations. On the other hand, infectious diseases had become more disruptive. In 1902, a plague in Kenya and a cholera in the Philippines killed 100,000 people (Beck, 1970, p. 7). But much progress had also been made in epidemiological research in the last two decades of the 19th century. On the whole, these two factors opened the door to more effective international public health cooperation in the 20th century. Building on the progress of the previous conferences, the international community held its first International Sanitary Conference of the 20th century in 1903. The conference discussed ways to test for diseases (mainly regarding notification and quarantines measures for cholera and plague) and the resulting International Sanitary Convention required member states to report information on malaria and plague.4 Participating countries also drafted International Sanitary Regulations, which set sanitary standards concerning ships and ports, inspections of ships, inspection certificates, segregation of infected ships and travellers and health checklists for people onboard. In fact, as Fidler (1999) maintained, 71% of the provisions were targeted at developing countries in the Middle East, Asia and Afr ica (p. 19). The mam concern of participating countries was about preventing the spread of disease from developing countries to developed countries and how to coordinate isolation measures. Tire ultimate purpose was to prevent economic losses of the maritime interests of Western powers (Goodman, 1971, p. 389).

Participants of the 1903 Conference asked France to support an ensuant meeting to focus on establishing an international organisation that would facilitate the sharing of information on outbreaks. As a result, countries around the world adopted the Rome Agreement on the Establishment of an Office international d’hygiène publique at the International Sanitary Conference in 1907, and subsequently set its headquarters in Paris. The Office had a permanent secretariat and a permanent committee of senior public health officials from 12 member states, trine of which were from Europe. The reason for the establishment of this permanent body was that at an international conference in Washington in 1902, led by the United States, the governments of the Americas had already joined together to set up the International Sanitary Bureau, a regional intergovernmental organisation. One of the most important features of the OIHP was its responsibility to

WHO and global health governance 61 collect information on diseases listed in the International Sanitary Regulations. In a way, “the Office international d’hygiène publique functions primarily as an international clearinghouse” (Stem & Market 2004, p. 1476). By the end of 1908, the permanent committee of the OIHP had hosted a total of two meetings and continued to host meetings biannually thereafter, though interrupted for five years due to World War I. The OIHP also prepared the International Sanitary' Conference in 1926, which added provisions for the control of smallpox and typhus to the International Sanitary Regulations and expanded the OIHP’s scope of disease control, hr short, the founding of the OIHP marked the beginning of the institutionalisation of international public health governance.

Stage 2: Establishment of the League of Nations Health Organization. After the scourge of World War I, countries around the world were eager to create a formal organisation to extend peace. As a result of the efforts, the international community established the League of Nations in 1919. Article 23 of its Charterstates that member states “will endeavour to take steps in matters of international concern for the prevention and control of disease”.5 To implement this provision, the International Community established the Health Organisation of the League of Nations (HOLN) in 1920. The founders believed that the HOLN should play a more prominent role in the management of typhus and influenza outbreaks after World War I. They also held that at that time all international public health regimes, including the International Sanitary Bureau and the Office international d’hygiène publique, should be placed under the supervision of the Leagtte of Nations. As the United States, being a member of the OIHP, refused to join the British- and French-led Leagtte of Nations, it naturally opposed any proposal to merge OIHP into the HOLN. As a result, in the years between the two world wars, two independent international health organisations co-existed in Europe— the OIHP and the HOLN. In 1923, the International Sanitary Bureau was renamed the Pan-American Sanitary Bureau, the predecessor of the Pan-American Health Organization. As the United States ascended as the biggest power in the Americas since the end of the 19th century, the nation had always attempted to implement the Monroe Doctrine and establish a hegemon in America. They resisted Europe’s interference in American affairs and always opposed any attempt to fuse the Pan-American Sanitary Bureau into global health organisations. Not until the end of World War II did the Pan-American Sanitary Bureau become one of the six regional offices of WHO.

During the two world wars, the international health regimes were paralysed by hostilities on both sides of the war. Three autonomous organisations, the HOLN in Geneva, the Pan-American Sanitary Bureau in Washington, and the Office international d’hygiène publique in Paris, coexisted and did not hold affiliations with one another. Each regime implemented conventions or treaties within its own sphere of influence. According to Javed Siddiqi, between 1920 and 1936 the League of Nations had suggested on four occasions that the Office international d’hygiène publique reform its international activities, eliminate overlapping functions and establish a single international health organisation. These recommendations were all rejected by the Office international d’hygiène publique.6 After the outbreak of World War II, with the dissolution of the League of Nations, the HOLN ceased to exist. Other international health regimes continued to operate independently until the Office international d’hygiène publique merged with the newly established World Health Organization in 1948. On the whole, despite the setbacks these health mechanisms endured and the protracted process through which international health conventions were settled, all the international health cooperation efforts demonstrate an irrefutable fact: Multilateral cooperation is an effective tool to jointly deal with the threat of micro-organisms.

Stage 3: Establishment of WHO. In 1945, after World War II ended, world leaders all agreed to hold an international conference on international organisations in San Francisco. The call for a new International Health Organization received increasing support. Tire meeting provided a wonderful opportunity to start discussions on setting up an effective world health organisation and formalised this organisation as a component of the United Nations system. Since representatives of the United States and the United Kingdom did not agree to include public health issues on the agenda, the proposal to establish a UN specialised health agency was not originally included in the charters of relevant international organisations of the United Nations reached at the San Francisco meeting. Only eventually and with strong support from the Brazil and China delegations holding that “medicine is one of the pillars of peace’’, was the proposal added to the Charter of the United Nations. A declaration was finally adopted at the meeting mandating health to be an area in which the United Nations shall participate (Lee, 1998, p. 4). However, writing the framework for the WHO charter was easier said than done. The United Nations Economic and Social Council agreed in February 1946 to convoke an international health conference in New York to “discuss the scope of international action in the public health field, appropriate approaches, and recommendations for a single United Nations World Health Organization” (ibid., p. 4). The meeting was prepared by a technical preparatory committee composed of 16 experts in the field of international health. From March to April 1946, the committee met in Paris to draw up a schedule and recommendations for discussion and prepared proposals on the governance structure, management, finances, trusteeships and even names of the new organisation. The International Health Conference was finally held between June 19 and July 22, 1946. Fifty-one Member States of the United Nations and 13 Non-member States participated in the meeting. In addition, observers from Germany, Japan, the Korean Allies management authorities and from relevant United Nations organisations also participated in the meeting. Tire delegations reached a consensus on the Constitution of the new organisation, the draft concerning the suspension of the Office international d’hygiène publique, the establishment of an interim commission to continue the work previously undertaken by the HOLN and the interim United Nations Relief and Rehabilitation Administration (UNRRA) (ibid., pp. 4-5). On April 7, 1948, WHO was officially established, making the day the annual “World Health Day”. The first Health Assembly opened in Geneva on June 24, 1948, with delegations from 53 of the 55 Member States. The interim commission ceased to exist on August 31, 1948, after the completion of its mission. Afterwards WHO took over

WHO and global health governance 63 international public health work, making it the first health organisation with a global dimension in the history of international public health cooperation.

 
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