See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/327634485

"The History of International Health: Medicine, Politics, and Two Socio-

Medical Perspectives, 1851 to 2000" In The Oxford Handbook of Global Health
Politics Edited by Colin McInnes...

Chapter · September 2018

CITATIONS READS

0 65

1 author:

Marcos Cueto
Fundação Oswaldo Cruz
80 PUBLICATIONS   2,002 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

History of AIDS View project

Trajectories and challenges of history of science in Latin America View project

All content following this page was uploaded by Marcos Cueto on 20 September 2018.

The user has requested enhancement of the downloaded file.

 1

The Oxford Handbook of Global Health Politics

Edited by Colin McInnes, Kelley Lee, and Jeremy Youde
September 2018

Draft: Chapter 2
The History of International Health: medicine, politics, and two socio-medical
perspectives, 1851 to 2000

Marcos Cueto, Oswaldo Cruz Foundation, FIOCRUZ, Rio de Janeiro

cuemarcos@gmail.com

Abstract
International health became an important activity of governments of industrialized and a
few Low-Income Countries (LICs) during the second half of the 19th-century. Initially
concentrated in improving, coordinating and standardizing quarantines, isolation of the
sick in ports and maritime health regulations, it became by the turn of the 20th century
an activity carried out by specialized institutions and a network of experts. Two socio-
medical approaches coexisted in international health during the 20th century; one
technocratic, illustrated in the malaria eradication campaign launched by the World
Health Organization (WHO) in the 1950s that relied heavily on technology. The other
one was exemplified by the Primary Health Care proposal made by the WHO and
UNICEF in the late 1970s that prioritized a broad prevention perspective and the use of
public health as a tool of social reform.

Insert 3-5 keywords History, International Health, Global Health, World Health
Organization, Primary Health Care.
 2

Although maritime sanitation rules in port-cities existed since the Middle Ages,
international health became a sustained intergovernmental activity only in the mid-19th
century. During the past few years, historical studies have examined this more recent
history examining how international health intertwined with imperialism, philanthropy,
humanitarianism, multilateralism, bilateralism, decolonization and development
(Amrith 2006; Birn 2009, Black 1996, Farley 2004; Harrison 2012; Packard 2016;
Watts 1997). These studies examine the process from ineffectual agreements in
response to epidemic outbreaks to permanent institutions. As an addition to this
historiography, this chapter argues that two visions ran parallel to one another in this
process. The first, hegemonic perspective was based on an excessive reliance on
Western medical technology and validated international health as a contribution to
global economic growth. The second perspective placed an emphasis on holistic
interventions, social reforms to improve people’s welfare and solidarity between
different countries. These visions will be examined, first, in the relationship between
Imperialism and the first international health agreements and institutions of the 19th
century and turn of the 20th century; and second, in the coexistence of different
proposals during the interwar period (1919-1939). Later I will analyze how these
visions reflected and interacted with the Cold War and health multilateralism, especially
in the development of the World Health Organization -a United Nation agency created
in 1948. Finally, this chapter will study the changes and continuities of the new field of
global health that emerged in the late 1980s and was closely related to the emergence of
Neoliberalism.

From international agreements to specialized institutions

Pandemics --epidemics that affect several countries simultaneously—massive
migration, and the expansion of maritime commerce, especially with colonial ports,
stimulated the first coordinated governmental decisions on international health. That
was the case of cholera, the most important pandemic of the 19th century. The disease,
which could be easily identified by the violent diarrhea and other dramatic symptoms
that it produced, was new to Europe and was presumed to have come from India (where
it was endemic) by means of steamships. From 1851, governments, mainly from
Western Europe and the US, organized a series of international sanitary conferences (11
by 1913). Initially, the objectives of these conferences were to improve and regulate
quarantines and standardize isolation compulsory measures for passengers suspected of
 3

having cholera (Howard Jones 1975; Stern & Merkel 2004). They made progress in
overcoming the ambiguous, erratic, and controversial maritime quarantine practices,
land controls and compulsory isolation hospitals of the turn of the 19th century and
facilitating national consensuses among merchants, diplomat and health leaders. The
agenda of these meetings was set by imperial European powers and the priorities of the
European tropical medicine around the protection of industrialized nations from
diseases coming from abroad, the protection of colonizers, the improvement of colonial
economies, and the construction of an image of “humanitarianism” to validate the
colonial enterprise. It was also important to establish outposts in Africa, Asia and other
tropical regions of the world as medical research enclaves that would produce results
that would be published in the metropolis and enhance the scientific prestige of Western
Medicine.
Some success occurred in articulating maritime sanitation with the economic
interests of merchants, who used to reject any sanitary control of goods and passengers
(Hardy 1993), although the confrontation of stigma and discrimination –that usually
blamed foreigners and the poor for epidemics—received less attention. However,
effective decisions came slowly because there was no agreement on what to do.
Initially, the first sanitary conferences achieved little consensus because of
disagreements between diplomats and physicians, and debates among medical doctors.
For example, it took some time for many representatives at the conferences to accept the
findings of British doctor John Snow, who since 1850 had argued that cholera could
spread in cities in water contaminated with feces of sick people (meaning that safe water
and sewage systems was the most effective control measures). Instead, many physicians
argued that the disease was not transmitted by direct exposure but had a miasmatic
origin in garbage and filth, and had to be addressed only with local hygiene.
International health experts’ attention was not solely focused on cholera
however. In 1871, a yellow fever epidemic killed thousands of people in Buenos Aires,
proving that the illness was not limited to the Caribbean –as previously believed-- and
could spread to other parts of the world. The Americans and Cubans pushed for the
inclusion of yellow fever in the agendas of international conferences. A physician who
played an important role in this process was the Cuban Carlos Finlay, who argued in the
1881 Washington, D.C. sanitary conference that the Aedis aegypt mosquito was
responsible for transmitting yellow fever and that controlling the mosquito population
was therefore essential for controlling disease transmission. His finding was part of a
 4

moment of ineffective agreements in international health - in this same conference, for

example, the US government failed to obtain the support from other governments for a
bill of health for any ship traveling to America. Experimental evidence on Finlay´s
work appeared only years later thanks to a US military commission led by Walter Reed,
who worked in Havana in 1900, in the wake of Cuba’s war of independence from Spain
(Espinosa 2009). These works inspired and helped public health physicians to reduce
the incidence of yellow fever in Havana and in cities of the Americas.
In addition to cholera and yellow fever, a third contagious disease was the
subject of meetings at the beginning of the 20th Century: bubonic plague. The illness
spread from Asia to the rest of the world, along with stigma against Asians (Echenberg
2007). Between 1895 and 1914, it seriously affected a number of countries, including
Portugal, Australia, South Africa, the USA, Brazil, Paraguay, Peru and Argentina.
Thanks to earlier efforts to stem yellow fever and the plague, as well as the advance of
bacteriology in medical schools, vector control was less controversial than it had been
during earlier debates about cholera. In Hong Kong and India, researchers in
bacteriology and parasitology showed that the plague was produced by bacteria that
were transmitted to humans through fleas found on rats. These discoveries led the way
to public health measures to control the plague including the elimination of rats in ports,
a serum to treat the disease and improved urban hygiene. These medical developments
occurred with a more permissive context for international health decisions. For
example, the seventh sanitary conference of 1892 approved a quarantine agreement for
the Suez Canal (which had been in operation since 1869 and was perceived by many
experts as cholera´s entry point to Western Europe). Furthermore, the sanitary
conference of 1897 adopted another convention to control plague.
To enlarge the work of sanitary conferences, governments and medical leaders
of Europe and the US decided in 1903 to consolidate all previous agreements in the
International Sanitary Convention (later called International Sanitary Regulations and
then International Health Regulations). The decision also entailed the creation of a
clearinghouse organization to centralize and ratify available data on epidemic outbreaks,
and supervise the implementation of the 1903 Convention. These are the origins of the
Office International d'Hygiène Publique (OIHP). The new agency operated in Paris
between 1907 and 1946, with a permanent secretariat and with regular meetings of a
committee of diplomats and public-health officers. Because a significant number of its
officers were diplomats, it was an agency where the political and medical goals co-
 5

existed in difficult terms (Paillete 2014). Its authority was also weakened by the First
World War (1914-1918), during which there was little cooperation between European
nations, while at the end of the war other agencies arose. Since 1919, for example, the
humanitarian International Federation of Red Cross Societies has been responsible for
bringing together voluntary work, while in Geneva the League of Nations established its
own health body (the League of Nations Health Organization (LNHO). Despite the fact
that it chose not to join the League because of its isolationist policies during this period,
US health authorities were part of both the LNHO and of the OIHP. (Borowy 2009).
Because of hostilities between member countries of the two agencies, it was not
possible to merge the LNHO and the OIHP (France, for example, was a defender of the
OIHP but did not agree with the LNHO). However, the leader of the LNHO, Ludwik J.
Rajchman, was a Polish doctor who became a champion in addressing the international
spread of disease by research, by helping the investigation to standardize drugs and
treatments, and by the promotion of improved life conditions for poor people around the
world (Balìnska 1995). This perspective was part of a European tradition known as
social medicine that can be traced to the 19th century but that only in the 20th was
institutionalized in professorial chairs, institutes and academic journals. Rajchman and
other staff at the LNHO, sought to promote this view of medical and social reform
outside Western Europe, including China, Bolivia and Greece (Borowy 2009a). In 1937,
the LNHO organized a landmark conference on rural hygiene in Bandung, Indonesia, --
after a proposal made by India and China-- which influenced social-medicine and
intersectoral perspectives for peasant’s health, the vast majority of LIC’s populations
(Brown & Fee 2008). In the years before the Second World War, however, Rajchman
had to abandon the League, as the LNHO’s director followed a policy of appeasement
with Nazi Germany, and he was considered a political “radical”. In addition to this, the
League of Nations’ capacity for action was limited; although there was much hope
invested in the institution, it did not have the political weight to impose its decisions and
did little against the Nazi invasion of Czechoslovakia in 1938 and of Poland in1939. In
the inter-war period from 1919 to 1939, therefore, the two official agencies of
international heath had little authority and lacked legitimacy. Rajchman´s departure was
a clear example how in critical times politics took precedence over medical priorities in
international health.
Another important organization from this period was the Rockefeller
Foundation, a philanthropic body founded in New York in 1913 (Barona Villar 2016).
 6

The Foundation interacted with the schools of tropical medicine in Europe, especially
the London and Liverpool schools in the UK, whose leaders had from their founding in
the turn of the 20th century an international –and more precisely colonial—scope and
perspective. Scientific races to establish the origins and the means of transmission of the
major infectious diseases that hit colonial people were part of the global narratives of
both the Foundation and of tropical medicine in the UK and other European countries.
Frequently, members of the Foundation, of schools of tropical medicine, international
agencies and supporters of social medicine attended the same meetings, published in
specialist journals and worked medical programs in colonial and post-colonial societies,
thus creating a network of expert knowledge in international health that reflected and
established power relations. (Neill 2012).
Unlike the OIHP or the OHNL, the Rockefeller Foundation did not represent any
government; it was the first major private philanthropy focused on international health.
The organization was financed from the fortune of John D. Rockefeller’s oil company,
and its medical objectives were to control hookworm disease, yellow fever and malaria
in poor countries, to control transmittable and chronic diseases in Europe, and to
promote a biomedical model of training of physicians and health personnel across the
globe. It was undoubtedly the most financially powerful international health
organization of the first half of the 20th century, with the largest staff who managed to
work with flexibility and autonomy to address a very broad set of issues, ranging from
supporting authoritarian public health programs to financing the LNHO’s efforts
towards integrated health and social medicine. The Rockefeller Foundation set up five
divisions, the most important being the International Health Division, which was
operational from 1918 to 1951. As in the case of tropical medicine, the Division worked
in a context marked by the expansion of European and American imperialism; the
trigger for the growth of a global market that required an international health which was
functional to its needs. However, recent studies suggest that Rockefeller officials
exhibited a greater degree of autonomy than the tropical-medicine doctors (Palmer
2010). In particular, several Rockefeller field officers appear to have abandoned the
priorities set in the headquarters of the Foundation in New York, and embraced the
public health and educational goals of local communities. Moreover, the Rockefeller
Foundation was a precursor of the modernization models of development of the Cold
War and of the US foreign policies of Americanization of medical and political elites.
 7

During the 19th and 20th centuries, regional international-health organizations

emerged in some regions in the world. These included the International Sanitary
Council of Egypt in Alexandria and the Pan American Sanitary Bureau (PASB),
established in 1902 (Cueto 2007). The PASB – which in 1958 changed its name to the
Pan American Health Organization (PAHO) – published in 1924 one of the first
international treaties that recognizes health as a duty of States and a right of all citizens.
In 1947, former Rockefeller Foundation officer, Fred L. Soper, was elected as PAHO’s
director, leading to a significant change in the Organization and reflecting wider
changes in the institutional landscape of international health. Soper’s move from the
Foundation to a multilateral agency was part of a new political context that led to the
rise of new bilateral and multilateral agencies. The leaders of the victorious nations of
World War II rejected the possibility of restoring the League of Nations, thereby giving
rise to the United Nations in 1945. During the establishment of the UN, the idea of
creating specialist agencies arose, such as the World Health Organization (WHO) and
UNICEF. The latter was founded in 1946 to provide food, clothing and health care to
children, first, of Europe, and later, to infants of poor countries. At same time, the
Rockefeller Foundation began to lose interest in international health and focused more
on technological advances in agriculture as part of a “green revolution” in LICs. As a
sub-product of this process, there was a migration of specialists from the Rockefeller
Foundation, exemplified by Soper, to multilateral agencies.

Enter the World Health Organization

The new international UN agency for health, the WHO, was founded in Geneva
in 1948, and replaced the other European agencies (OIHP and the LNHO), but made an
agreement with the PAHO to be its regional representative in the Americas. It was
created with a visionary perspective laid out in the founding document of the WHO as
part of the preamble to its 1948 Constitution and is an example of the second, holistic
perspective to health care. It affirms that health does not only consist of the absence of
illness, but is a fundamental human right and an obligation of states (Cueto, Brown &
Fee 2011).
The first Director General of the WHO was the Canadian psychiatrist, Brock
Chisholm, who remained in the position from 1948 to 1953 (Farley 2008). During this
period, the WHO established regional offices in Southeast Asia, Europe, the Eastern
Mediterranean, the Western Pacific and in sub-Saharan Africa (the latter only after
 8

some resistance from the imperialist nations France, Belgium, Portugal and Britain). In
regions that comprised a significant number of LICs, such as South-Asia and Africa, the
early years of the WHO experienced an ongoing tension between centralisation and
uniformity of response, according to the desires of Geneva headquarters, and more
regional power and sensitivity to local needs, as pressured by members countries. The
WHO assumed a number of roles including reconstructing old health systems for
prevention and treatment in European countries where they had been destroyed, as well
as creating new ones in other countries where they had not previously existed; and
creating a system for epidemiological information.
After its establishment in 1948, the WHO had to work with the backdrop of the
Cold War and the political rivalry between the US and Soviet Union. The capitalist
countries sought to contain the Soviet expansion into new parts of the world, while the
Moscow government intensified efforts to intervene in the internal politics of countries
that were politically significant on account of their location. The result was a hardening
of relations between the two superpowers. A precursor to these Cold War tensions
became manifest in the WHO when the Soviet Union left the agency between 1949 and
1956. The official reason given was its dissatisfaction with the work carried by the UN
and the WHO. Nevertheless, the underlying reasons were that the Russians and the
Americans had opposite visions of public health. The Soviets believed in a direct
relationship between social and health problems. They attributed the underlying causes
behind illnesses to the precarious working conditions of the population at large and to
capitalist exploitation. In the Soviet Union, private medical practice was prohibited and
health services were nationalized (as was the case with a number of sectors of the
economy), while in the US a mixed model involving private and public-sector doctors
and the supremacy of a network of private hospitals prevailed.
In July 1955, the Soviet Union chose to return to the WHO, a decision
influenced by the death in 1953 of Joseph Stalin, the hardline communist leader. The
new Soviet leader, Nikita Khruschev, guided by the goals of “peaceful coexistence” and
de-Stalinization, offered to help emergent poor nations to achieve political and
economic independence from European colonial powers and US economic dependency.
The Soviet strategy of spreading Communism as a pathway to progress led to
competition between the superpowers for hegemony amongst LIC nations. The attention
to these nations was elicited by the wave of decolonization and “third-world”
movements that emerged in countries of Africa, Asia and elsewhere during the late
 9

1950s and 1960s. These countries frequently had governments keenly aware of their
new independence seeking technical assistance from multilateral organizations. It was
in this context of a tense relationship in the Cold War --during the 1950s and 1960s--
that the WHO began to work with some autonomy. The second Director General, the
Brazilian Marcolino Candau, was elected in 1953 and it was at this time that the
organization strengthened its infrastructure and consolidated its prestige as an
intergovernmental institution (Cueto & Reinalda 2015). Many WHO staff sought to
show their loyalty to the agency itself, and not to their own national governments, as
part of the process of establishing an incipient international civil service. Legitimacy
was also gained from the WHO’s Assembly –the organization’s governing body of
member states which, in the first years of the its existence, were held in different cities
around the globe-- where a Director General and an Executive Council were elected
with the responsibility of defining general directives. In addition, the WHO connected
experts throughout the world in specialized committees (that usually coopted one or
more members form a LIC) on a series of issues such as biological standardization,
medical education and malaria control (some important World Health Assembly
resolutions where validated by reports of these committees). These were real epistemic
communities of experts that established the frontiers of “acceptable” knowledge and
could dismiss at best as “unorthodox” and at worst as simply “mistaken” other
proposals. Another example of its growing legitimacy was the success in 1969 of the
legally-binding International Health Regulation that concentrated in cholera, plague,
smallpox and yellow fever (valid until 2005, when negotiations on revisions were
successfully concluded) (Fidler 2001).
A parallel development in the 1960s was the emergence of international health
as an academic subfield of studies, and research that concentrated on low-income
countries (LICs). For example, in 1961 a formal program on international health was
created at Johns Hopkins’ School of Public Health and seven years later it became the
independent Department of International Health under the leadership of Carl Taylor.
Taylor was an advisor to the WHO when at Johns Hopkins, especially concerning
community health and what became the Primary Health Care proposal of 1978, and
was the founding chair of the International Health Section of the American Public
Health Association. Many consider him the founder of the academic discipline of
international health in the US; a field constructed in terms of the needs of LICs, rather
than relations between states, based on the assumptions that industrialized nations knew
 10

what was good for the medicine and public health of both poorer nations and of High
Income Countries (HICs)(Brown and Fee 2011).
Nonetheless, for financial reasons, the WHO’s independence was relative (Lee
2009). In the post-war period, the US was the main funder of the WHO and contributed
more than a third of the overall budget. America maintained good relations with the
agency because it generally held the majority of votes in the governing health
assemblies and had well-funded bilateral international health agencies. Therefore, the
US government retained an important degree of independence in international health
matters. Although the US State Department had had health cooperation organs since the
1940s, the most important was not established until 1961 as a unit within USAID (the
US Agency for International Development). Shortly thereafter, other industrialized
countries created and relied on their own bilateral agencies, that in time concentrated
more human and financial resources, than multilateral agencies. The creation of these
bilateral agencies made technical assistance and international health programs an
intrinsic dimension of the foreign policies of donor nations. Again, medicine and
politics appeared in a new combination --that favored the latter-- in the history of
international health.
Candau was re-elected Director General of the WHO in 1958, 1963 and 1968,
and stayed in the post until 1973. In the 1950s and early 1960s, the most important
global health programs were the so-called vertical campaigns, which were clear
examples of the first, technocratic perspective of international health. They generally
involved actions that sought to eradicate a specific infectious disease by means of
certain technologies, alongside complex administrative and financial operations. In
addition, these campaigns had advantages for some High-Income Countries. In terms of
national security, it was a means to protect their own territory against diseases coming
from abroad. Another reason was the interest in global economic productivity: at the
start of the 1950s, the US and other industrialized nations had investments spread across
the globe and were concerned in protecting the consumption of its products. The
campaigns were also themselves a form of indirect subsidy to some US industries, since
guidelines were laid down for the procurement of US medication and medical
technology. A prominent example of this was the then widely promoted insecticide
dichlorodiphenyltrichloroethane (DDT, used to control mosquitos that carried malaria).
DDT was largely produced in the US by oil companies that found an important
opportunity to sell insecticides thanks to the malaria eradication campaign.
 11

The WHO’s most important vertical campaign was carried out to address a
typically rural disease: malaria, characterized by intermittent fevers that are generally
non-fatal but reduce the capacity for work and have a negative impact on agriculture
and business. It was a clear example of the first perspective described at the beginning
of this chapter - a reliance on medical technology which validated international health
as a contribution to global economic growth - because the justification for its
elimination portrayed it as an “economic” disease. In other words, disease eradication
was a socio-medical intervention for the improvement of national and the world´s
economies. The means used was technological in the form of insecticides (DDT) and
medication. In spite of some doubts over these - some reports warned of DDT not being
sufficiently effective against mosquitos, while medication did not always eliminate the
infectious agent, Plasmodium falciparum - the 8th World Health Assembly held in
Mexico in 1955 approved the eradication of malaria (Cueto 2007a). National
autonomous programs were established in almost all countries in the world. The
determination to eliminate the disease was notable for its almost limitless confidence in
the power of science to overcome nature. For defenders of the program, eradication was
better than control, which sought to contain the illness by means such as drainage of
wetlands and the administration of quinine to infected people. In particular, control was
considered to be ineffective and, in the long term, more expensive because it required
the growing use of material and human resources and significant investment in
environmental health. The malaria eradication programs – which were set to culminate
after five to eight years of work – were conceived as a tool for the construction of health
systems. Many WHO staff believed that the core of good health ministries were
eradication programs for major illnesses, starting with malaria. This belief went against
the definition of health that was set out in the preamble to the agency’s constitution,
which stated that health was not simply the absence of illness. The results of the
program however were limited to a reduction in the incidence of the disease, usually in
modernized areas of countries (Siddiqi 1995). The three explanations for the failure of
the campaign against malaria are: a decline in political will, an increase in the number
of people living in endemic areas (including migrants and nomads), and the fact that
mosquitos’ resistance to insecticides was greater than had been expected.
In the 1960s, politicians from HICs and some multilateral agencies, such as the
World Bank, thought that the main problem of poor countries was not malaria but
overpopulation. According to this viewpoint, it was more important to ensure family-
 12

planning programs than to fight against infectious diseases; the fight against malaria
was even considered to be counterproductive because it contributed towards an increase
in the population in poor countries. Family planning was first influential in private
organizations, then in bilateral and finally multilateral agencies. All became convinced
that decreasing population growth would have a strong impact on the capitalist
economic development of poor nations. During the 1960s, bilateral foundations and
agencies from Highly Industrialized Nations began to raise concerns about the negative
impacts of overpopulation, and implemented birth control programs. The first defenders
of population control interventions were the International Planned Parenthood
Federation, the Population Council, and the Ford Foundation, who managed to convince
the US government of the importance of birth control. They argued that a high
proportion of populations lived in urban areas of LICs due to high birth rates and waves
of migrants from rural areas. In 1965, USAID established an office responsible for
promoting population control in LICs that, in the following years, grew its budget
substantially and operated as a centrally-managed global program. In the same year, the
US President, Lyndon B. Johnson, argued that every five dollars invested in population
control was the equivalent of 100 dollars invested in economic development. For
subsequent Presidents – Richard Nixon, Gerald Ford and Jimmy Carter – reducing
population growth was a common cause (Necochea López 2014). As a consequence, the
US Food and Drug Administration (FDA) authorized the sale of contraceptive methods
including the IUD (intrauterine device) and approved the sale of contraceptive pills, and
USAID became the largest bilateral organization donating condoms, contraceptives, and
educational programs on family planning (mostly part of examples of the first
international health perspective). One of the political justifications for implementing
family planning was the fear that poor and over-populated countries would be
influenced by communism because their lack of infrastructure made providing food and
jobs for an increasing number of people difficult. In this political context, LICs put into
practice programs aimed at limiting the growth of their populations, generally targeting
poor women (a notable exception being India, which prioritized male sterilization,
frequently poor males, through vasectomies).
At this time, Catholic country members of the WHO did not consider population
growth to be a problem and retained nationalist pro-birth policies. The Soviet Union and
most communist countries—with the exception of China-- viewed the concerns about
over-population as a pretext to obstruct the potential rise of future revolutionaries by
 13

capitalist countries. These opponents of family planning were convinced that LICs
needed more inhabitants in order to increase their economic and military potential. As
an indication of the lack of consensus in the WHO based on political considerations of
member states, some WHO directives were against abortion, while others supported it
along with family planning. However, those bilateral agencies and private sector
organizations that supported birth control never had much confidence in the capacity of
the WHO to lead an international program for family planning. Thus, in 1969, the
United Nations Population Fund, (UNFPA), was created and managed by the United
Nations Development Programme (UNDP). In 1972, in recognition of the reach of its
operations, UNFPA was placed under the responsibility of the United Nations General
Assembly and given the same status as UNDP and UNICEF, a decision which created
jurisdictional problems with the WHO.
In the 1970s, the WHO gave in to pressure from population control programs of
the bilateral agencies and philanthropic organizations. A factor that contributed to this
change was the fact that the Soviet Union changed its traditional pro-natality policies to
reduce the number of illegal abortions carried out in the country. In the early 1970s, the
WHO set up a Special Programme of Research, Development and Research Training in
Human Reproduction. However, the political landscape that supported these programs
changed once again in the 1980s, not least with the arrival of conservative governments
in the US and Europe and the rising significance of human-rights and feminist groups.
These groups denounced the gender, racial and social bias of these vertical family-
planning programs aimed to control the lives of women and the poor. They harshly
criticized compulsory sterilization in India, China and other LICs. The Indian
government offered financial compensation to individuals who underwent sterilization,
while the Chinese birth control program (which promoted abortion and only allowed
couples to have one child) also came under attack. Conservatives joined the criticism
questioning whether reducing population growth actually contributed to economic
growth in poor nations. Consequently, US foreign policy towards population control
changed dramatically with Presidents Ronald Reagan and George H. W. Bush
suspending the support of family planning international agencies. A turning point was
Mexico City´s International Conference on Population of 1984, where the US
announced that recipients of bilateral aid had to agree, as a condition of receiving
assistance, to neither perform, discuss nor promote abortion as a method of family
planning. Paradoxically, all this occurred when many governments in LICs were in
 14

favor of population control and the birth rates began to fall in non-industrialized
countries.
Just as the criticisms and debate of disease control programs were gaining some
traction and family planning programs experienced problems in their implementation,
the most important success in the history of international health occurred: the
eradication of smallpox. This was the result of a program developed in the 1960s and
1970s. A supporting factor was the policy of détente, between the Soviet Union and the
USA, with the formal aims of maintaining peace, promoting technical cooperation and
reaching a balance between the rival blocks (Reinhardt 2015). The fight against
smallpox had been instigated by the Soviet Union within the WHO in the early 1960s
and gained further support when the American Donald Henderson, who worked at the
US Centers for Disease Control and Prevention, was named program head in Geneva. In
the WHO smallpox program, new methodologies were implemented consisting mainly
of intensive surveillance and interventions focused in regions that were most affected by
the disease. The campaign allowed a new generation of public health officials to cut
their teeth by implementing policies that were different from the malaria eradication
campaign. The most important change was the abandoning of a rigid and authoritarian
plan for the health programs and the goal of mass vaccination (or reaching 80 to 100 %
people of a given country vaccinated). Instead, surveillance and containment in areas
where cases have been reported became the means and the goals of campaigns. These
efforts led to success: by 1980, smallpox had been completely eradicated across the
globe (Bhattacharya 2006) and was a major spur for applying other immunization
programs around the world (Muraskin 1998).

The Vicissitudes of Primary Health Care

Smallpox eradication occurred in a general discussion of the new goals for
international health. The discussion shaped Primary Health Care (PHC), a socio-
medical strategy emblematic of the second perspective described in the beginnings of
this chapter. PHC arose towards the end of the 1960s, at a time when the hegemony of
the US was in crisis during the Vietnam War, when more African and Caribbean nations
were becoming independent of European colonial rule, when anti-imperialist
movements on the left were organizing, and when the economic and political recovery
of Canada and Western Europe assisted LICs in the establishment of social and public
health infrastructures. PHC was influenced by a number of initiatives. First, a notable
 15

1974 Canadian report, named after the Minister of Health Marc Lalonde, outlined four
factors that determined the health of a given population: biology, health services,
environment and lifestyle. Therefore, the modernization of health services could not be
divorced from other socio-medical factors. Secondly, social scientists who had no
background in public health criticized the idea that the good health of industrialized
countries was the result of an increase in the number of doctors who had graduated from
university. Third, PHC was inspired by the popularity of “barefoot” rural doctors in
communist China, who were part of groups of health workers who lived in the
communities that they served. These doctors placed greater importance on rural
outreach as opposed to urban care, carried out preventative activities and mixed
Western medicine with traditional Chinese medicine. Finally, during the early 1970s
some agencies, mainly UNICEF, the UN International Labor Organization and USAID,
de-emphasized technical assistance programs and adopted a “basic human needs”
approach, which prioritized integral programs in nutrition, family planning,
development of health infrastructure, and basic education in shantytowns and rural
areas. These influences were important to a number of public health leaders, including
the charismatic Danish doctor Halfdan Mahler who was elected director general of the
WHO in 1973 (and subsequently re-elected twice, holding the post until 1988) and was
a stern supporter of PHC.
The most important event for PHC was the International Conference on Primary
Health Care, organized by the WHO and UNICEF in September 1978 in Alma-Ata
(now Almaty), the capital of the Kazakh Soviet Socialist Republic (Cueto 2004). The
conference’s final Declaration included an ambitious goal: “Health for all by the year
2000”. The Declaration contained a criticism of hospitals and overspecialized medical
teams that were deemed too expensive, sophisticated or irrelevant for the necessities of
poor people. In contrast, an “appropriate” technology – meaning being affordable,
sustainable and directed to treat and prevent common diseases-- – was the alternative to
meet poor people’s needs. At the same time, the instalment of health posts in rural areas
was prioritized over the construction of specialized hospitals. Finally, the Declaration
associated good health systems with social development; and work in healthcare was
conceived as part of broader attempts to improve people’s life conditions. PHC was
therefore positioned at the center of the health system and in a number of articles,
Mahler defended the idea that health should be an instrument of development and not
simply a by-product of economic progress (Litsios 2008).
 16

One year after the PHC meeting in Alma Ata, a new concept arose: Selective
Primary Health Care (SPHC). Supporters of this new idea considered the Alma-Ata
Declaration to be too idealistic because of its ambitious timeline and vague target of
health for all by the year 2000. Instead, since 1979, the Rockefeller Foundation, leaders
from bilateral agencies and UNICEF began to work on identifying specific interventions
for infant illnesses, including diarrhea and malnutrition. Although the content and
interventions of SPHC were not clear at first, in subsequent years (particularly in the
first half of the 1980s), these were encapsulated in the acronym GOBI - Growth
monitoring, Oral rehydration, Breastfeeding and Immunization. The first intervention
was focused on identifying children who did not grow in line with the ideal height and
weight for their age. For this, appropriate nutrition was the solution. Another was the
control of diarrhea related diseases by means of oral rehydration therapies known as
ORT. The third sought to emphasize the nutritional and psychological importance of
breastfeeding during the child’s first months. The final intervention was immunization,
which focused on the vaccination of children to protect them from common ailments.
SPHC received the full support of UNICEF, which was then run by James Grant (who
had been appointed executive director of the organization shortly after the Alma-Ata
Conference).
In the years that followed Alma Ata, these two approaches to international health
came to loggerheads. The first, SPHC, was supported by public health specialists who
believed in a restricted roll-out of PHC, placing a priority on the use of modern
technology and on the leadership role of health professionals in controlling selected
diseases. The second, which was approved in Alma Ata, required cooperation between
doctors and community leaders in order to construct multifunctional health posts and
centers. This cooperation would also promote the improvement of the living conditions
of the poor. Supporters of this second viewpoint, including Mahler, saw SPHC as a
technocratic approach that was similar to vertical programs. In addition, critics pointed
out that some interventions had complications: the promotion of breast-feeding would
go against the interests of powerful industries that supported artificial infant formula
milk; and rehydration programs were no more than a palliative for communities who
had no safe water systems. The World Health Assembly tried to overcome some of
these problems and approved in 1981 an International Code of Marketing of Breast-
milk Substitutes that banned advertisement or promotion of these products to the public,
but only a few countries implemented it effectively.
 17

One of the problems faced by the concept proposed by Mahler after Alma-Ata
was that it was not clear how PHC was to be financed. Unlike other campaigns, such as
the eradication of malaria in the 1950s when funds came mainly from the US, there
were not significant resources for PHC in the WHO. Another problem was that a large
proportion of the medical professionals working in poor countries had an individual
goal to work in specialized urban hospitals (few embraced the possibility of living in
rural areas, as would be ideal under PHC). Doctors were resistant to PHC because they
thought it was not based on scientific research, while many considered traditional
medicine primitive and ineffective. As a result, Primary Health Care did not become the
center of health systems; instead most governments adopted GOBI, or some GOBI
interventions such as immunization and distribution of ORT, and turned them into
vertical programs. In the mid-1980s, Mahler found himself largely isolated in Geneva in
his quest to promote a broader-based PHC. In 1988, he concluded his third mandate as
director general of the WHO and was replaced by the Japanese doctor, Hiroshi
Nakajima who remained in the post until 1998. Japan, a country perceived by many as a
rising global industrial power, enthusiastically supported Nakajima. As a result, experts
expected Japan to provide the necessary financial resources to support the WHO, but in
the end, these were not significant (Walt 1993). Furthermore, important international
health conference occurred with little participation of the WHO, such as the 1994
International Conference on Population and Development that took place in Cairo,
which equated gender equity and the new subfield of sexual and reproductive health.

AIDS and new epidemic challenges

While PHC and SPHC were being debated, a new and unexpected disease,
HIV/AIDS, altered the priorities of international agencies (see Whiteside chapter in this
volume). It was first recorded in Los Angeles in 1981 in young homosexual men with a
number of opportunistic illnesses that usually affected old people or those with
damaged immunological systems, such as Pneumocystis carinii fungus and Kaposi's
sarcoma (Fee and Fox 1988). Not long after, cases were recorded among hemophiliacs –
who were dependent on blood transfusions – and injection drug users. In the early years,
stigmatizing names emerged such as the 4-H disease because it seemed to affect
Haitians, homosexual, hemophiliacs and heroin-users. The acronym ‘GRID’ (Gay-
Related Immune Deficiency) reinforced stigma. Once it had been determined that the
disease was not limited to the homosexual community, discriminatory terms were
 18

replaced by the acronym AIDS (acquired immunodeficiency syndrome). Initially it was

perceived as a disease of rich countries but by the mid-1980s, it was clear that it was
spread all over the world.
The WHO was initially slow to respond to AIDS. The first director of the Global
Program for AIDS, created only in 1987, was the American doctor Jonathan Mann,
under whom it became the WHO’s largest program for addressing a single disease. For
perhaps the first time, medical investigations and public health interventions were put
into practice alongside human rights promotion, allowing a disease to be addressed
concomitantly from scientific, clinical and political perspectives. Mann chided stigma
and discrimination and promoted confidential testing and educational programs as well
as the use of condoms as broad strategies for prevention (Fee and Parry 2008). The
AIDS program promoted a greater cultural awareness and tolerance to sexual minorities
and was closer to the second socio-medical perspective described in this chapter
because it placed emphasis on the social and cultural context of ill people and their
partners and families. Mann´s firm stand on international health helped to raise funds
and make the disease --and indirectly international health-- a priority of ministers of
finance and presidents. However, Mann entered into conflict with the Director General
of the WHO, Nakajima, who did not agree with the program’s scope, leading to the
former resigning from his position and moving to the US. Sadly, he died in an airplane
accident in 1998 on his way to a meeting of the recently established Joint United
Nations Programme on HIV/AIDS (UNAIDS), an agency directed by the Belgian
doctor Peter Piot, that brought together ten organizations of the UN system. UNAIDS
became the main driver for global action against AIDS and took over the leadership role
from the WHO in its fight against the HIV/AIDS
In the wake of AIDS, during the final decade of the 20th Century outbreaks of
old and new bacterial, viral and parasitical diseases occurred in unexpected places.
Examples include the diphtheria epidemic in Russia in 1990, cholera in Peru in 1991,
yellow fever in Kenya in 1992 and bubonic plague in India in 1994, as well as dengue
epidemics in Latin America in 1996 and 1997. Scientists created two terms for the new
epidemiological situation: emerging and reemerging diseases. Both could appear in any
part of the world and spread rapidly to another part because of the ease of movement of
people, goods, animals and foods. These terms were both a harbinger of, and
contributed to the discursive shift from” “international” to “global health.” Although
there was no precise definition for an emerging disease, it was considered one whose
 19

microbiological cause or clinical manifestation appeared among humans for the first
time. The term ‘re-emerging’ was attributed to contagious diseases that reappeared in a
geographic area after a period of prolonged absence. Both type of diseases were the
unpredictable result of climate change, and increased national, regional and
international mobility and migration (that produced greater contact between populations
that had previously been more isolated before). Most studies agreed that there were
social causes to this, including the collapse of public health infrastructure both in LIC
countries (many of which were occasioned by the World Bank’s structural adjustment
policies linked to development loans, see chapter in this volume on ‘Critical approaches
to International Political Economy and Health’) and in countries from the former Soviet
bloc, where the transition of socialist economies and health infrastructures to market
systems proved difficult and created unstable societies with people vulnerable to
disease.
Alongside these emerging and reemerging diseases, new transnational NGOs
acquired greater relevance, along with patient groups that made demands including
access to treatment and drugs (especially groups of people living with HIV and AIDS,
see Whiteside chapter in this volume), thereby increasing the number of actors in
international health. Among the new actors, one of the most important was the French
Médecins sans Frontières (MSF, or Doctors without Borders). This was a network of
physicians, initially founded in 1971, whose work focused on providing medical
assistance to refugees and populations affected by epidemics and was awarded the
Nobel Peace Prize in 1999. MSF blazed the trail for other international non-profit
organizations like Partners in Health created in 1987 in Boston.
During this period, the WHO was perceived as a troubled agency incapable of
responding rapidly to new epidemiological challenges. Neoliberal governments,
criticized multilateral agencies portraying them as troubled, bloated and inefficient
bureaucracies that reflected the realities of the Cold War era which had ended in 1990,
and was incapable of carrying out an internal reform. The WHO’s leadership in
international health was also waning in light of the changes caused by the trans-
nationalization of finance and the aggressive activities of other international
organizations, particularly the World Bank that, since 1979, had an active Population,
Health and Nutrition Department. The health policies of the Bank, which were
consistent with neoliberal economic policies (see chapter in this volume on ‘Critical
approaches to International Political Economy and Health’), became a dominant force in
 20

international health soon after the report entitled Investing in Health of 1993.
Importantly, by the 1990s the World Bank budget for international health was greater
than the total budget of the WHO (Ruger 2005). Moreover, the autonomy of the main
multilateral health agency was at risk: the World Health Assembly did not control about
two thirds of the money the WHO spent because of the magnitude of donations which
were ring-fenced by member states for specific programs (Linden 2014). At this same
time, some experts began to argue that the new term “global health” should replace the
term “international health” because health problems were transnational and should be
resolved by means of supranational measures through a collection of public and private
partners (Brown, Cueto and Fee 2006). Initially, the role of the WHO was not clear in
this new framework of “global” health. Thus, the WHO began to lose its leadership
position on the international stage (although this was partially reversed with the
appointment of a new Director General, Gro Harlem Bruntland, in 1998, a trained
physician who had spent most of her life as a leading politician in his home country,
Norway, and a leader of environmental causes in the world).

Conclusion
Change in international health frequently was precipitated not so much by new
biomedical or public health innovation, as changes to the global political order such as
the expansion and intensification of empires, migration, trade routes and maritime
commerce, the legacies of the two world wars, the surge and crisis of the Cold War, the
growing pressure for independence and de-colonization, and Neoliberalism. Medical
reactions to these developments included tropical medicine, medical philanthropy,
social medicine, Primary Health Care and Selective Primary Health Care. Thus, the
history of international health cannot be divorced from broader political, economic and
social events. Nevertheless, the first accords and international health organizations left
important legacies such a degree of cooperation between commercial and medical
interests, the construction of an epidemiological network of experts around the world
and the International Health Regulations. During the 20th century, agencies did not limit
themselves to communicating and controlling the damages of epidemic outbreaks, but
oscillated between two socio-medical perspectives that had political connotations. One
was to promote medical and social reforms to change the life conditions that led to
epidemics (as defended by the LNHO and stated in the WHO´s Constitution Preamble
of 1948). In a similar vein, the original concept of PHC was shaped. A different
 21

perspective was to conceive international health as a tool to protect local, national and
global economies under the assumption that the health of populations was a byproduct
of economic growth (as the arguments to validate the malaria eradication program of the
1950s did). The debate, tension and accommodation of these two socio-medical
perspectives however would persist until the turn of the 21st century. Underlying their
history helps to illuminate daunting contemporary problems of international health:
fragmentation, discontinuity, and problematic governance (Lidén 2014).
 22

Reference List
Amrith, Sunil S. 2006. Decolonizing International Health, India and South Asia, 1930
-1965. Hapshire: Plagrave.

Balìnska, Marta. 1995. Une vie pour l’humanitaire: Ludwik Rajchman (1881-1965).
Paris: Editions La Decouverte.

Barona Villar, Joseph L. 2016. The Rockefeller Foundation, public health, and
international diplomacy, 1920-1945. London: Routledge.

Bhattacharya, Sanjoy. 2006. Expunging variola: the control and eradication of

smallpox in India, 1947-1977. New Delhi: Orient Longman.

Birn, Ann Emanuelle. 2009. “The stages of international (global) health: histories of
success or successes of history?” Global Public Health 4(1):50-68

Black, Maggie. 1996. Children First: The Story of UNICEF, Past and Present Oxford:
Oxford University Press.

Borowy, Iris, 2009. Coming to terms with world health: the League of Nations Health
Organization, 1921-1946. Frankfurt am Main: Peter Lang.

Borowy, Iris. 2009a. Uneasy encounters: the politics of medicine and health in China,
1900-1937. Frankfurt am Maim: Peter Lang.

Brown, Theodore M., and Elizabeth Fee. 2008. “The Bandoeng Conference of 1937: A
Milestone in Health and Development.” American Journal of Public Health 98(1): 42–
43.

Brown, Theodore M., and Elizabeth Fee. 2011. “Carl E. Taylor, (1916-2010): a beloved
pioneer in international health.” American Journal of Public Health
101(7):1216.
 23

Brown, Theodore M., Marcos Cueto and Elizabeth Fee. 2006. “The World Health
Organization and the transition from "international" to "global" public health.
American Journal of Public Health 96(1):62-72.

Cueto, Marcos. 2004. The Origins of Primary Health Care and Selective Primary Health
Care.” American Journal of Public Health 94(11): 1864-1874.

_____. 2007. The value of health: a history of the Pan American Health
Organization. Rochester, NY: University of Rochester Press.

_____. 2007a. Cold war, deadly fevers: malaria eradication in Mexico, 1955-1975.
Baltimore: Johns Hopkins University Press.

Cueto, Marcos, Theodore Brown and Elizabeth Fee. 2011 “El proceso de creación de la
Organización Mundial de la Salud y la Guerra Fría” Apuntes: Revista de
Ciencias Sociales 38(69): 129-156.

Cueto, Marcos and Bob Reinalda. 2015. “Candau, Marcolino Gomes’” in IO BIO,
Biographical Dictionary of Secretaries-General of International Organizations,
Edited by Bob Reinalda, Kent J. Kille and Jaci Eisenberg, www.ru.nl/fm/iobio
[Accessed 28 November 2016].

Echenberg, Myron J. 2007. Plague ports: the global urban impact of bubonic
plague, 1894-1901. New York: New York University Press.

Espinosa, Mariola. 2009. Epidemic invasions: yellow fever and the limits of Cuban
independence, 1878-1930. Chicago: The University of Chicago Press.

Farley, John. 2004. To Cast Out Disease: A History of the International Health Division
of the Rockefeller Foundation (1913-1951). Oxford: Oxford University Press.

_____. 2008. Brock Chisholm, the World Health Organization, and the Cold War.
Vancouver: UBC Press.
 24

Fee, Elizabeth and Daniel M. Fox, eds. 1988. AIDS: the burdens of history. Berkeley:
University of California Press.

Fee Elizabeth and Parry Marion. 2008. “Jonathan Mann, HIV/AIDS, and human rights.”
Journal of Public Health Policy 29(1):54-71.

Fidler, David P. 2001 “The globalization of public health: the first 100 years of
international health diplomacy.” Bulletin of the World Health Organization
79(9):842-849.

Hardy, Ann. 1993 “Cholera, quarantine and the English preventive system, 1850-1895.”
Medical History 37(3):250-269.

Harrison, Mark. 2012. Contagion: how commerce has spread disease. New Haven:
Yale University Press.

Howard-Jones, Norman. 1975. The scientific background of the International

Sanitary Conferences, 1851-1938. Geneva: World Health Organization.

Lidén, J. 2014. “The World Health Organization and Global Health Governance: post
1990.” Public Health. 128(2):141-147 [SEE last paragraph] Commented [JF1]: Missing in text

Lee, Kelley. 2009 World Health Organization (WHO). London: Routledge.

Litsios, Socrates. 2008. The third ten years of the World Health Organization,
1968-1977. Geneva: World Health Organization.

Muraskin, William. 1998. The Politics of International Health: The Children's Vaccine
Initiative and the Struggle to Develop Vaccines for the Third World. Albany:
State University of New York Press.

Necochea López, Raúl. 2014. A history of family planning in twentieth-century Peru.

Chapel Hill: The University of North Carolina Press.
 25

Neill, Deborah J. 2012. Networks in Tropical Medicine: Internationalism, Colonialism,

and the Rise of a Medical Specialty, 1890–1930. Stanford: Stanford University Press.

Packard, Randall M. 2016 A history of global health: interventions into the lives of
other peoples. Baltimore: Johns Hopkins University Press.

Paillete, Céline. 2014. “Diplomatie et globalisation des enjeux sanitaires. Camille

Barrère, un itinéraire diplomatique du Caire à l'Office international d'hygiène
publique (1883-1926)”. Hypothèses 17: 129-138.

Palmer, Steven. 2010. Launching Global Health: The Caribbean Odyssey of the
Rockefeller Foundation. Ann Arbor: University of Michigan Press, 2010.

Reinhardt, Bob H. 2015. The end of a global pox: America and the eradication of
smallpox in the Cold War era. Chapel Hill: The University of North Carolina
Press.

Ruger, J.P. 2005. “The changing role of the World Bank in global health.” American
Journal of Public Health 95(1):60-67.

Siddiqi, Javed. 1995. World Health and World Politics: The World Health
Organization and the UN System. Columbia: University of South Carolina Press.

Stern, Alexandra and Howard Merkel. 2004. “International Efforts to Control Infectious
Diseases, 1851 to the Present,” Journal of the American Medical Association
292(12): 1474–1479.

Walt, Gill. 1993. “WHO under Stress: Implications for Health Policy,” Health Policy
24(2):125-144.

Watts, Sheldon. 1997. Epidemics and history: disease, power, and imperialism. New
Haven: Yale University Press.

View publication stats