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1. Home
2. American Journal of Public Health (ajph)
3. January 2006
THE WORLD HEALTH ORGANIZATION AND THE TRANSITION FROM “INTERNATIONAL” TO
“GLOBAL” PUBLIC HEALTH
Theodore M. BrownPhD, ,Marcos CuetoPhD, and ,Elizabeth FeePhD
Affiliation
Theodore M. Brown is with the Department of History and the Department of
Community and Preventive Medicine, University of Rochester, Rochester, NY.
Marcos Cueto is with the Facultad de Salud Pública, Universidad Peruana Cayetano
Heredia, Lima, Peru. Elizabeth Fee is with the History of Medicine Division,
National Library of Medicine, National Institutes of Health, Bethesda, Md.
COPYRIGHT
Peer Reviewed
Contributors All authors contributed equally to the research and writing.
https://doi.org/10.2105/AJPH.2004.050831
Accepted: January 11, 2005
Published Online: October 10, 2011
* Abstract
* Full Text
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ABSTRACT
Section:
ChooseTop of pageAbstract <<THE WORLD HEALTH ORGANIZA...Crisis at WHO,
1988–1998WHO EMBRACES “GLOBAL HEAL...CONCLUSIONReferencesCITING ARTICLES
The term “global health” is rapidly replacing the older terminology of
“international health.” We describe the role of the World Health Organization
(WHO) in both international and global health and in the transition from one to
the other. We suggest that the term “global health” emerged as part of larger
political and historical processes, in which WHO found its dominant role
challenged and began to reposition itself within a shifting set of power
alliances.
Between 1948 and 1998, WHO moved from being the unquestioned leader of
international health to being an organization in crisis, facing budget
shortfalls and diminished status, especially given the growing influence of new
and powerful players. We argue that WHO began to refashion itself as the
coordinator, strategic planner, and leader of global health initiatives as a
strategy of survival in response to this transformed international political
context.
EVEN A QUICK GLANCE AT THE titles of books and articles in recent medical and
public health literature suggests that an important transition is under way. The
terms “global,” “globalization,” and their variants are everywhere, and in the
specific context of international public health, “global” seems to be emerging
as the preferred authoritative term.1 As one indicator, the number of entries in
PubMed under the rubrics “global health” and “international health” shows that
“global health” is rapidly on the rise, seemingly on track to overtake
“international health” in the near future (Table 1). Although universities,
government agencies, and private philanthropies are all using the term in highly
visible ways,2 the origin and meaning of the term “global health” are still
unclear.
We provide historical insight into the emergence of the terminology of global
health. We believe that an examination of this linguistic shift will yield
important fruit, and not just information about fashions and fads in language
use. Our task here is to provide a critical analysis of the meaning, emergence,
and significance of the term “global health” and to place its growing popularity
in a broader historical context. In particular, we focus on the role of the
World Health Organization (WHO) in both international and global health and as
an agent in the transition from one concept to the other.
Let us first define and differentiate some essential terms. “International
health” was already a term of considerable currency in the late 19th and early
20th century, when it referred primarily to a focus on the control of epidemics
across the boundaries between nations (i.e., “international”).
“Intergovernmental” refers to the relationships between the governments of
sovereign nations—in this case, with regard to the policies and practices of
public health. “Global health,” in general, implies consideration of the health
needs of the people of the whole planet above the concerns of particular
nations. The term “global” is also associated with the growing importance of
actors beyond governmental or intergovernmental organizations and agencies—for
example, the media, internationally influential foundations, nongovernmental
organizations, and transnational corporations. Logically, the terms
“international,” “intergovernmental,” and “global” need not be mutually
exclusive and in fact can be understood as complementary. Thus, we could say
that WHO is an intergovernmental agency that exercises international functions
with the goal of improving global health.
Given these definitions, it should come as no surprise that global health is not
entirely an invention of the past few years. The term “global” was sometimes
used well before the 1990s, as in the “global malaria eradication program”
launched by WHO in the mid-1950s; a WHO Public Affairs Committee pamphlet of
1958, The World Health Organization: Its Global Battle Against Disease3; a 1971
report for the US House of Representatives entitled The Politics of Global
Health4; and many studies of the “global population problem” in the 1970s.5 But
the term was generally limited and its use in official statements and documents
sporadic at best. Now there is an increasing frequency of references to global
health.6 Yet the questions remain: How many have participated in this shift in
terminology? Do they consider it trendy, trivial, or trenchant?
Supinda Bunyavanich and Ruth B. Walkup tried to answer these questions and
published, under the provocative title “US Public Health Leaders Shift Toward a
New Paradigm of Global Health,” their report of conversations conducted in 1999
with 29 “international health leaders.”7 Their respondents fell into 2 groups.
About half felt that there was no need for a new terminology and that the label
“global health” was meaningless jargon. The other half thought that there were
profound differences between international health and global health and that
“global” clearly meant something transnational. Although these respondents
believed that a major shift had occurred within the previous few years, they
seemed unable clearly to articulate or define it.
In 1998, Derek Yach and Douglas Bettcher came closer to capturing both the
essence and the origin of the new global health in a 2-part article on “The
Globalization of Public Health” in the American Journal of Public Health.8 They
defined the “new paradigm” of globalization as “the process of increasing
economic, political, and social interdependence and integration as capital,
goods, persons, concepts, images, ideas and values cross state boundaries.” The
roots of globalization were long, they said, going back at least to the 19th
century, but the process was assuming a new magnitude in the late 20th century.
The globalization of public health, they argued, had a dual aspect, one both
promising and threatening.
In one respect, there was easier diffusion of useful technologies and of ideas
and values such as human rights. In another, there were such risks as diminished
social safety nets; the facilitated marketing of tobacco, alcohol, and
psychoactive drugs; the easier worldwide spread of infectious diseases; and the
rapid degradation of the environment, with dangerous public health consequences.
But Yach and Bettcher were convinced that WHO could turn these risks into
opportunities. WHO, they argued, could help create more efficient information
and surveillance systems by strengthening its global monitoring and alert
systems, thus creating “global early warning systems.” They believed that even
the most powerful nations would buy into this new globally interdependent world
system once these nations realized that such involvement was in their best
interest.
Despite the long list of problems and threats, Yach and Bettcher were largely
uncritical as they promoted the virtues of global public health and the
leadership role of WHO. In an editorial in the same issue of the Journal, George
Silver noted that Yach and Bettcher worked for WHO and that their position was
similar to other optimistic stances taken by WHO officials and advocates. But
WHO, Silver pointed out, was actually in a bad way: “The WHO’s leadership role
has passed to the far wealthier and more influential World Bank, and the WHO’s
mission has been dispersed among other UN agencies.” Wealthy donor countries
were billions of dollars in arrears, and this left the United Nations and its
agencies in “disarray, hamstrung by financial constraints and internal
incompetencies, frustrated by turf wars and cross-national policies.”9 Given
these -realities, Yach and Bettcher’s promotion of “global public health” while
they were affiliated with WHO was, to say the least, intriguing. Why were these
spokesmen for the much-criticized and apparently hobbled WHO so upbeat about
“global” public health?
THE WORLD HEALTH ORGANIZATION
Section:
ChooseTop of pageAbstractTHE WORLD HEALTH ORGANIZA... <<Crisis at WHO,
1988–1998WHO EMBRACES “GLOBAL HEAL...CONCLUSIONReferencesCITING ARTICLES
The Early Years
To better understand Yach and Bettcher’s role, and that of WHO more generally,
it will be helpful to review the history of the organization from 1948 to 1998,
as it moved from being the unquestioned leader of international health to
searching for its place in the contested world of global health.
WHO formally began in 1948, when the first World Health Assembly in Geneva,
Switzerland, ratified its constitution. The idea of a permanent institution for
international health can be traced to the organization in 1902 of the
International Sanitary Office of the American Republics, which, some decades
later, became the Pan American Sanitary Bureau and eventually the Pan American
Health Organization.10 The Rockefeller Foundation, especially its International
Health Division, was also a very significant player in international health in
the early 20th century.11
Two European-based international health agencies were also important. One was
the Office Internationale d’Hygiène Publique, which began functioning in Paris
in 1907; it concentrated on several basic activities related to the
administration of international sanitary agreements and the rapid exchange of
epidemiological information.12 The second agency, the League of Nations Health
Organization, began its work in 1920.13 This organization established its
headquarters in Geneva, sponsored a series of international commissions on
diseases, and published epidemiological intelligence and technical reports. The
League of Nations Health Organization was poorly budgeted and faced covert
opposition from other national and international organizations, including the US
Public Health Service. Despite these complications, which limited the Health
Organization ’s effectiveness, both the Office Internationale d’Hygiène Publique
and the Health Organization survived through World War II and were present at
the critical postwar moment when the future of international health would be
defined.
An international conference in 1945 approved the creation of the United Nations
and also voted for the creation of a new specialized health agency. Participants
at the meeting initially formed a commission of prominent individuals, among
whom were René Sand from Belgium, Andrija Stampar from Yugoslavia, and Thomas
Parran from the United States. Sand and Stampar were widely recognized as
champions of social medicine. The commission held meetings between 1946 and
early 1948 to plan the new international health organization. Representatives of
the Pan American Sanitary Bureau, whose leaders resisted being absorbed by the
new agency, were also involved, as were leaders of new institutions such as the
United Nations Relief and Rehabilitation Administration (UNRRA).
Against this background, the first World Health Assembly met in Geneva in June
1948 and formally created the World Health Organization. The Office
Internationale d’Hygiène Publique, the League of Nations Health Organization,
and UNRRA merged into the new agency. The Pan American Sanitary Bureau—then
headed by Fred L. Soper, a former Rockefeller Foundation official—was allowed to
retain autonomous status as part of a regionalization scheme.14 WHO formally
divided the world into a series of regions—the Americas, Southeast Asia, Europe,
Eastern Mediterranean, Western Pacific, and Africa—but it did not fully
implement this regionalization until the 1950s. Although an “international” and
“intergovernmental” mindset prevailed in the 1940s and 1950s, naming the new
organization the World Health Organization also raised sights to a worldwide,
“global” perspective.
The first director general of WHO, Brock Chisholm, was a Canadian psychiatrist
loosely identified with the British social medicine tradition. The United
States, a main contributor to the WHO budget, played a contradictory role: on
the one hand, it supported the UN system with its broad worldwide goals, but on
the other, it was jealous of its sovereignty and maintained the right to
intervene unilaterally in the Americas in the name of national security. Another
problem for WHO was that its constitution had to be ratified by nation states, a
slow process: by 1949, only 14 countries had signed on.15
As an intergovernmental agency, WHO had to be responsive to the larger political
environment. The politics of the Cold War had a particular salience, with an
unmistakable impact on WHO policies and personnel. Thus, when the Soviet Union
and other communist countries walked out of the UN system and therefore out of
WHO in 1949, the United States and its allies were easily able to exert a
dominating influence. In 1953, Chisholm completed his term as director general
and was replaced by the Brazilian Marcolino Candau. Candau, who had worked under
Soper on malaria control in Brazil, was associated first with the “vertical”
disease control programs of the Rockefeller Foundation and then with their
adoption by the Pan American Sanitary Bureau when Soper moved to that agency as
director.16 Candau would be director general of WHO for over 20 years. From 1949
until 1956, when the Soviet Union returned to the UN and WHO, WHO was closely
allied with US interests.
In 1955, Candau was charged with overseeing WHO’s campaign of malaria
eradication, approved that year by the World Health Assembly. The ambitious goal
of malaria eradication had been conceived and promoted in the context of great
enthusiasm and optimism about the ability of widespread DDT spraying to kill
mosquitoes. As Randall Packard has argued, the United States and its allies
believed that global malaria eradication would usher in economic growth and
create overseas markets for US technology and manufactured goods.17 It would
build support for local governments and their US supporters and help win “hearts
and minds” in the battle against Communism. Mirroring then-current development
theories, the campaign promoted technologies brought in from outside and made no
attempt to enlist the participation of local populations in planning or
implementation. This model of development assistance fit neatly into US Cold War
efforts to promote modernization with limited social reform.18
With the return of the Soviet Union and other communist countries in 1956, the
political balance in the World Health Assembly shifted and Candau accommodated
the changed balance of power. During the 1960s, malaria eradication was facing
serious difficulties in the field; ultimately, it would suffer colossal and
embarrassing failures. In 1969, the World Health Assembly, declaring that it was
not feasible to eradicate malaria in many parts of the world, began a slow
process of reversal, returning once again to an older malaria control agenda.
This time, however, there was a new twist; the 1969 assembly emphasized the need
to develop rural health systems and to integrate malaria control into general
health services.
When the Soviet Union returned to WHO, its representative at the assembly was
the national deputy minister of health. He argued that it was now scientifically
feasible, socially desirable, and economically worthwhile to attempt to
eradicate smallpox worldwide.19 The Soviet Union wanted to make its mark on
global health, and Candau, recognizing the shifting balance of power, was
willing to cooperate. The Soviet Union and Cuba agreed to provide 25 million and
2 million doses of freeze-dried vaccine, respectively; in 1959, the World Health
Assembly committed itself to a global smallpox eradication program.
In the 1960s, technical improvements—jet injectors and bifurcated needles—made
the process of vaccination much cheaper, easier, and more effective. The United
States’ interest in smallpox eradication sharply increased; in 1965, Lyndon
Johnson instructed the US delegation to the World Health Assembly to pledge
American support for an international program to eradicate smallpox from the
earth.20 At that time, despite a decade of marked progress, the disease was
still endemic in more than 30 countries. In 1967, now with the support of the
world’s most powerful players, WHO launched the Intensified Smallpox Eradication
Program. This program, an international effort led by the American Donald A.
Henderson, would ultimately be stunningly successful.21
The Promise and Perils of Primary Health Care, 1973–1993
Within WHO, there have always been tensions between social and economic
approaches to population health and technology-or disease-focused approaches.
These approaches are not necessarily incompatible, although they have often been
at odds. The emphasis on one or the other waxes and wanes over time, depending
on the larger balance of power, the changing interests of international players,
the intellectual and ideological commitments of key individuals, and the way
that all of these factors interact with the health policymaking process.
During the 1960s and 1970s, changes in WHO were significantly influenced by a
political context marked by the emergence of decolonized African nations, the
spread of nationalist and socialist movements, and new theories of development
that emphasized long-term socioeconomic growth rather than short-term
technological intervention. Rallying within organizations such as the
Non-Aligned Movement, developing countries created the UN Conference on Trade
and Development (UNCTAD), where they argued vigorously for fairer terms of trade
and more generous financing of development.22 In Washington, DC, more liberal
politics succeeded the conservatism of the 1950s, with the civil rights movement
and other social movements forcing changes in national priorities.
This changing political environment was reflected in corresponding shifts within
WHO. In the 1960s, WHO acknowledged that a strengthened health infrastructure
was prerequisite to the success of malaria control programs, especially in
Africa. In 1968, Candau called for a comprehensive and integrated plan for
curative and preventive care services. A Soviet representative called for an
organizational study of methods for promoting the development of basic health
services.23 In January 1971, the Executive Board of the World Health Assembly
agreed to undertake this study, and its results were presented to the assembly
in 1973.24 Socrates Litsios has discussed many of the steps in the
transformation of WHO’s approach from an older model of health services to what
would become the “Primary Health Care” approach.25 This new model drew upon the
thinking and experiences of nongovernmental organizations and medical
missionaries working in Africa, Asia, and Latin America at the grass-roots
level. It also gained saliency from China’s reentry into the UN in 1973 and the
widespread interest in Chinese “barefoot doctors,” who were reported to be
transforming rural health conditions. These experiences underscored the urgency
of a “Primary Health Care” perspective that included the training of community
health workers and the resolution of basic economic and environmental
problems.26
These new approaches were spearheaded by Halfdan T. Mahler, a Dane, who served
as director general of WHO from 1973 to 1988. Under pressure from the Soviet
delegate to the executive board, Mahler agreed to hold a major conference on the
organization of health services in Alma-Ata, in the Soviet Union. Mahler was
initially reluctant because he disagreed with the Soviet Union’s highly
centralized and medicalized approach to the provision of health services.27 The
Soviet Union succeeded in hosting the September 1978 conference, but the
conference itself reflected Mahler’s views much more closely than it did those
of the Soviets. The Declaration of Primary Health Care and the goal of “Health
for All in the Year 2000” advocated an “intersectoral” and multidimensional
approach to health and socioeconomic development, emphasized the use of
“appropriate technology,” and urged active community participation in health
care and health education at every level.28
David Tejada de Rivero has argued that “It is regrettable that afterward the
impatience of some international agencies, both UN and private, and their
emphasis on achieving tangible results instead of promoting change . . . led to
major distortions of the original concept of primary health care.”29 A number of
governments, agencies, and individuals saw WHO’s idealistic view of Primary
Health Care as “unrealistic” and unattainable. The process of reducing
Alma-Ata’s idealism to a practical set of technical interventions that could be
implemented and measured more easily began in 1979 at a small conference—heavily
influenced by US attendees and policies—held in Bellagio, Italy, and sponsored
by the Rockefeller Foundation, with assistance from the World Bank. Those in
attendance included the president of the World Bank, the vice president of the
Ford Foundation, the administrator of USAID, and the executive secretary of
UNICEF.30
The Bellagio meeting focused on an alternative concept to that articulated at
Alma-Ata—“Selective Primary Health Care”—which was built on the notion of
pragmatic, low-cost interventions that were limited in scope and easy to monitor
and evaluate. Thanks primarily to UNICEF, Selective Primary Health Care was soon
operationalized under the acronym “GOBI” (Growth monitoring to fight
malnutrition in children, Oral rehydration techniques to defeat diarrheal
diseases, Breastfeeding to protect children, and Immunizations).31
In the 1980s, WHO had to reckon with the growing influence of the World Bank.
The bank had initially been formed in 1946 to assist in the reconstruction of
Europe and later expanded its mandate to provide loans, grants, and technical
assistance to developing countries. At first, it funded large investments in
physical capital and infrastructure; in the 1970s, however, it began to invest
in population control, health, and education, with an emphasis on population
control.32 The World Bank approved its first loan for family planning in 1970.
In 1979, the World Bank created a Population, Health, and Nutrition Department
and adopted a policy of funding both stand-alone health programs and health
components of other projects.
In its 1980 World Development Report, the Bank argued that both malnutrition and
ill health could be countered by direct government action—with World Bank
assistance.33 It also suggested that improving health and nutrition could
accelerate economic growth, thus providing a good argument for social sector
spending. As the Bank began to make direct loans for health services, it called
for more efficient use of available resources and discussed the roles of the
private and public sectors in financing health care. The Bank favored free
markets and a diminished role for national governments.34 In the context of
widespread indebtedness by developing countries and increasingly scarce
resources for health expenditures, the World Bank’s promotion of “structural
adjustment” measures at the very time that the HIV/AIDS epidemic erupted drew
angry criticism but also underscored the Bank’s new influence.
In contrast to the World Bank’s increasing authority, in the 1980s the prestige
of WHO was beginning to diminish. One sign of trouble was the 1982 vote by the
World Health Assembly to freeze WHO’s budget.35 This was followed by the 1985
decision by the United States to pay only 20% of its assessed contribution to
all UN agencies and to withhold its contribution to WHO’s regular budget, in
part as a protest against WHO’s “Essential Drug Program,” which was opposed by
leading US-based pharmaceutical companies.36 These events occurred amidst
growing tensions between WHO and UNICEF and other agencies and the controversy
over Selective versus Comprehensive Primary Health Care. As part of a rancorous
public debate conducted in the pages of Social Science and Medicine in 1988,
Kenneth Newell, a highly placed WHO official and an architect of Comprehensive
Primary Health Care, called Selective Primary Health Care a “threat . . . [that]
can be thought of as a counter-revolution.”37
In 1988, Mahler’s 15-year tenure as director general of WHO came to an end.
Unexpectedly, Hiroshi Nakajima, a Japanese researcher who had been director of
the WHO Western Pacific Regional Office in Manila, was elected new director
general.38
Crisis at WHO, 1988–1998
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The first citizen of Japan ever elected to head a UN agency, Nakajima rapidly
became the most controversial director general in WHO’s history. His nomination
had not been supported by the United States or by a number of European and Latin
American countries, and his performance in office did little to assuage their
doubts. Nakajima did try to launch several important initiatives—on tobacco,
global disease surveillance, and public–private partnerships—but fierce
criticism persisted that raised questions about his autocratic style and poor
management, his inability to communicate effectively, and, worst of all,
cronyism and corruption.
Another symptom of WHO’s problems in the late 1980s was the growth of
“extrabudgetary” funding. As Gill Walt of the London School of Hygiene and
Tropical Medicine noted, there was a crucial shift from predominant reliance on
WHO’s “regular budget”—drawn from member states’ contributions on the basis of
population size and gross national product—to greatly increased dependence on
extrabudgetary funding coming from donations by multilateral agencies or “donor”
nations.39 By the period 1986–1987, extrabudgetary funds of $437 million had
almost caught up with the regular budget of $543 million. By the beginning of
the 1990s, extra-budgetary funding had overtaken the regular budget by $21
million, contributing 54% of WHO’s overall budget.
Enormous problems for the organization followed from this budgetary shift.
Priorities and policies were still ostensibly set by the World Health Assembly,
which was made up of all member nations. The assembly, however, now dominated
numerically by poor and developing countries, had authority only over the
regular budget, frozen since the early 1980s. Wealthy donor nations and
multilateral agencies like the World Bank could largely call the shots on the
use of the extrabudgetary funds they contributed. Thus, they created, in effect,
a series of “vertical” programs more or less independent of the rest of WHO’s
programs and decisionmaking structure. The dilemma for the organization was that
although the extrabudgetary funds added to the overall budget, “they [increased]
difficulties of coordination and continuity, [caused] unpredictability in
finance, and a great deal of dependence on the satisfaction of particular
donors,”40 as Gill Walt explained.
Fiona Godlee published a series of articles in 1994 and 1995 that built on
Walt’s critique.41 She concluded with this dire assessment: “WHO is caught in a
cycle of decline, with donors expressing their lack of faith in its central
management by placing funds outside the management’s control. This has prevented
WHO from [developing] . . . integrated responses to countries’ long term
needs.”41
In the late 1980s and early 1990s, the World Bank moved confidently into the
vacuum created by an increasingly ineffective WHO. WHO officials were unable or
unwilling to respond to the new international political economy structured
around neoliberal approaches to economics, trade, and politics.42 The Bank
maintained that existing health systems were often wasteful, inefficient, and
ineffective, and it argued in favor of greater reliance on private-sector health
care provision and the reduction of public involvement in health services
delivery.43
Controversies surrounded the World Bank’s policies and practices, but there was
no doubt that, by the early 1990s, it had become a dominant force in
international health. The Bank’s greatest “comparative advantage” lay in its
ability to mobilize large financial resources. By 1990, the Bank’s loans for
health surpassed WHO’s total budget, and by the end of 1996, the Bank’s
cumulative lending portfolio in health, nutrition, and population had reached
$13.5 billion. Yet the Bank recognized that, whereas it had great economic
strengths and influence, WHO still had considerable technical expertise in
matters of health and medicine. This was clearly reflected in the Bank’s widely
influential World Development Report, 1993: Investing in Health, in which credit
is given to WHO, “a full partner with the World Bank at every step of the
preparation of the Report.”44 Circumstances suggested that it was to the
advantage of both parties for the World Bank and WHO to work together.
WHO EMBRACES “GLOBAL HEALTH”
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This is the context in which WHO began to refashion itself as a coordinator,
strategic planner, and leader of “global health” initiatives. In January 1992,
the 31-member Executive Board of the World Health Assembly decided to appoint a
“working group” to recommend how WHO could be most effective in international
health work in light of the “global change” rapidly overtaking the world. The
executive board may have been responding, in part, to the Children’s Vaccine
Initiative, perceived within WHO as an attempted “coup” by UNICEF, the World
Bank, the UN Development Program, the Rockefeller Foundation, and several other
players seeking to wrest control of vaccine development.45 The working group’s
final report of May 1993 recommended that WHO—if it was to maintain leadership
of the health sector—must overhaul its fragmented management of global,
regional, and country programs, diminish the competition between regular and
extrabudgetary programs, and, above all, increase the emphasis within WHO on
global health issues and WHO’s coordinating role in that domain.46
Until that time, the term “global health” had been used sporadically and,
outside WHO, usually by people on the political left with various “world”
agendas. In 1990, G. A. Gellert of International Physicians for the Prevention
of Nuclear War had called for analyses of “global health interdependence.”47 In
the same year, Milton and Ruth Roemer argued that further improvements in
“global health” would be dependent on the expansion of public rather than
private health services.48 Another strong source for the term “global health”
was the environmental movement, especially debates over world environmental
degradation, global warming, and their potentially devastating effects on human
health.49
In the mid-1990s, a considerable body of literature was produced on global
health threats. In the United States, a new Centers for Disease Control and
Prevention (CDC) journal, Emerging Infectious Diseases, began publication, and
former CDC director William Foege started using the phrase “global infectious
disease threats.”50 In 1997, the Institute of Medicine’s Board of International
Health released a report, America’s Vital Interest in Global Health: Protecting
Our People, Enhancing Our Economy, and Advancing Our International Interests.51
In 1998, the CDC’s Preventing Emerging Infectious Diseases: A Strategy for the
21st Century appeared, followed in 2001 by the Institute of Medicine’s
Perspectives on the Department of Defense Global Emerging Infections
Surveillance and Response System.52 Best-selling books and news magazines were
full of stories about Ebola and West Nile virus, resurgent tuberculosis, and the
threat of bioterrorism.53 The message was clear: there was a palpable global
disease threat.
In 1998, the World Health Assembly reached outside the ranks of WHO for a new
leader who could restore credibility to the organization and provide it with a
new vision: Gro Harlem Brundtland, former prime minister of Norway and a
physician and public health professional. Brundtland brought formidable
expertise to the task. In the 1980s, she had been chair of the UN World
Commission on Environment and Development and produced the “Brundtland Report,”
which led to the Earth Summit of 1992. She was familiar with the global thinking
of the environmental movement and had a broad and clear understanding of the
links between health, environment, and development.54
Brundtland was determined to position WHO as an important player on the global
stage, move beyond ministries of health, and gain a seat at the table where
decisions were being made.55 She wanted to refashion WHO as a “department of
consequence”55 able to monitor and influence other actors on the global scene.
She established a Commission on Macroeconomics and Health, chaired by economist
Jeffrey Sachs of Harvard University and including former ministers of finance
and officers from the World Bank, the International Monetary Fund, the World
Trade Organization, and the UN Development Program, as well as public health
leaders. The commission issued a report in December 2001, which argued that
improving health in developing countries was essential to their economic
development.56 The report identified a set of disease priorities that would
require focused intervention.
Brundtland also began to strengthen WHO’s financial position, largely by
organizing “global partnerships” and “global funds” to bring together
“stakeholders”—private donors, governments, and bilateral and multilateral
agencies—to concentrate on specific targets (for example, Roll Back Malaria in
1998, the Global Alliance for Vaccines and Immunization in 1999, and Stop TB in
2001). These were semiautonomous programs bringing in substantial outside
funding, often in the form of “public–private partnerships.”57 A very
significant player in these partnerships was the Bill & Melinda Gates
Foundation, which committed more than $1.7 billion between 1998 and 2000 to an
international program to prevent or eliminate diseases in the world’s poorest
nations, mainly through vaccines and immunization programs.58 Within a few
years, some 70 “global health partnerships” had been created.
Brundtland’s tenure as director general was not without blemish nor free from
criticism. Some of the initiatives credited to her administration had actually
been started under Nakajima (for example, the WHO Framework Convention on
Tobacco Control), others may be looked upon today with some skepticism (the
Commission on Macroeconomics and Health, Roll Back Malaria), and still others
arguably did not receive enough attention from her administration (Primary
Health Care, HIV/AIDS, Health and Human Rights, and Child Health). Nonetheless,
few would dispute the assertion that Brundtland succeeded in achieving her
principal objective, which was to reposition WHO as a credible and highly
visible contributor to the rapidly changing field of global health.
CONCLUSION
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We can now return briefly to the questions implied at the beginning of this
article: how does a historical perspective help us understand the emergence of
the terminology of “global health” and what role did WHO play as an agent in its
development? The basic answers derive from the fact that WHO at various times in
its history alternatively led, reflected, and tried to accommodate broader
changes and challenges in the ever-shifting world of international health. In
the 1950s and 1960s, when changes in biology, economics, and great power
politics transformed foreign relations and public health, WHO moved from a
narrow emphasis on malaria eradication to a broader interest in the development
of health services and the emerging concentration on smallpox eradication. In
the 1970s and 1980s, WHO developed the concept of Primary Health Care but then
turned from zealous advocacy to the pragmatic promotion of Selective Primary
Health Care as complex changes overtook intra-and interorganizational dynamics
and altered the international economic and political order. In the 1990s, WHO
attempted to use leadership of an emerging concern with “global health” as an
organizational strategy that promised survival and, indeed, renewal.
But just as it did not invent the eradicationist or primary care agendas, WHO
did not invent “global health”; other, larger forces were responsible. WHO
certainly did help promote interest in global health and contributed
significantly to the dissemination of new concepts and a new vocabulary. In that
process, it was hoping to acquire, as Yach and Bettcher suggested in 1998, a
restored coordinating and leadership role. Whether WHO’s organizational
repositioning will serve to reestablish it as the unquestioned steward of the
health of the world’s population, and how this mission will be effected in
practice, remains an open question at this time.
TABLE 1— Number of Articles Retrieved by PubMed, Using “International Health”
and “Global Health” as Search Terms, by Decade: 1950 Through July 2005
TABLE 1— Number of Articles Retrieved by PubMed, Using “International Health”
and “Global Health” as Search Terms, by Decade: 1950 Through July 2005
DecadeInternational HealthaGlobal Healtha1950s1 007541960s3 3031551970s8 3691
1371980s16 9247 1761990s49 15827 7942000–July 200552 169b39 759b
aPicks up variant term endings (e.g. “international” also picks up
“internationalize” and “internationalization”; “global” also picks up
“globalize” and “globalization”).
bNumber for 55 months only.
“War on the Malaria Mosquito!” Poster produced by the Division of Public
Information, World Health Organization, Geneva, 1958. Courtesy of the World
Health Organization. Source: Prints and Photographs Collection of the National
Library of Medicine.
Smallpox Vaccination Program in Togo, 1967. Courtesy of the Centers for Disease
Control and Prevention. Source: Public Health Image Library, CDC.
Alma Ata Conference, 1978. Courtesy of the Pan American Health Organization.
Source: Office of Public Information, PAHO.
Current Director General Jongwook Lee with three former Directors-General at the
celebration to mark the 25th Anniversary of the Alma Ata Declaration. From left:
G. H. Brundtland, H. Mahler, H. Nakajima, Lee JW. Courtesy of the World Health
Organization. Source: Media Center, WHO.
The authors are grateful to the Joint Learning Initiative of the Rockefeller
Foundation, which initially commissioned this article, and to the Global Health
Histories Initiative of the World Health Organization, which has provided a
supportive environment for continuing our research.
References
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Picked up by 17 news outlets
Referenced in 3 policy sources
Posted by 38 X users
Referenced in 19 Wikipedia pages
981 readers on Mendeley
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CITATIONS
648 Total citations
71 Recent citations
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ARTICLE CITATION
Theodore M. Brown, PhD, Marcos Cueto, PhD, and Elizabeth Fee, PhDTheodore M.
Brown is with the Department of History and the Department of Community and
Preventive Medicine, University of Rochester, Rochester, NY. Marcos Cueto is
with the Facultad de Salud Pública, Universidad Peruana Cayetano Heredia, Lima,
Peru. Elizabeth Fee is with the History of Medicine Division, National Library
of Medicine, National Institutes of Health, Bethesda, Md. “The World Health
Organization and the Transition From “International” to “Global” Public Health”,
American Journal of Public Health 96, no. 1 (January 1, 2006): pp. 62-72.
https://doi.org/10.2105/AJPH.2004.050831
PMID: 16322464
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