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Has the World Health Organization measured up?

May 22, 2019

cover of the book THE WORLD HEALTH ORGANIZATION: A HISTORY includes an image of a hand with a syringeFounded in 1948 in the aftermath of World War II, the World Health Organization is a specialized agency of the United Nations focused on international public health. Headquartered in Geneva, Switzerland, it was specifically tasked with the lofty goal of ensuring the “highest possible level of health” by all peoples, regardless of race, political belief, religion, economic status, or social condition.

Seventy years later—has the WHO measured up? The reality is complicated, says Theodore Brown, University of Rochester professor emeritus of history and public health sciences.

A well-known expert on the history of US and international public health, Brown’s research interests run the gamut from US health policy and politics, to the history of psychosomatic medicine, stress research, and biopsychosocial approaches to clinical practice.

The struggle between ‘verticalists’ and ‘horizontalists’

The constant undercurrent at the WHO has been a struggle in vision between two dueling camps: on one side the agency’s “verticalists” who believe that the primary actions should be biomedically-based technical interventions—and on the other side the “horizontalists” who believe that the role of international agencies is to help countries and areas build up their own health infrastructures, while getting local players involved in maintaining and preserving their populations’ health.

These two main perspectives essentially govern all of the agency’s actions, explains Brown: The preamble to the WHO’s constitution holds that diseases are caused and sustained socially and economically, requiring a broad societal response—the view espoused by the “horizontalists.” However, the second, vertical perspective presumes that epidemic diseases are biomedical events that need technical interventions alone to tame them, such as better vaccines and improved technologies.

“That’s a battle that’s been raging within international health for well over a century,” says Brown, who had been the University’s Charles E. and Dale L. Phelps Professor of Public Health and Policy for five years, before he retired in 2018.

Brown set out with two co-authors—Marcos Cueto, a professor at the Casa de Oswaldo Cruz, a unit of Fiocruz, the main Brazilian biomedical institute, and the late Elizabeth Fee, who was the senior historian at the National Library of Medicine—to evaluate the successes and failures of critical WHO campaigns, among them eradication programs for malaria and smallpox, to today’s continued struggles against Ebola.

The result is The World Health Organization: A History (Cambridge University Press, 2019), a comprehensive look at how world politics—including the dynamics of the Cold War in the early decades, and later the increasing involvement of governmental and private players—have influenced and shaped the organization, its operations, and ultimately affected the fate of its mission.

The problems with the vertical approach is that it’s usually a top-down approach to public health that gives little consideration to the participation of the community, argues co-author Cueto. Often that means an overemphasis on technological solutions—such as trying to find a “golden bullet” like DDT for malaria—instead of striking a balance between biomedical technology, and improving the living conditions, lifestyles and environment of poor communities.” The problem, Cueto says, is that this vertical approach usually focuses on a specific—often infectious— disease instead of a comprehensive attack on a series of diseases.

Successes

According to the authors, during its first decades, the United Nations’ specialized health agency was the “acknowledged international leader on matters of health and disease and was at the center of a global network of scientists, physicians, and health policy makers.” During the second half of the 20th century, the WHO “played a preeminent role in the political validation of international health as a field and helped shape the notion of technical health assistance for developing countries.”

Theodore Brown

Theodore Brown, University of Rochester professor emeritus of history and public health sciences, has co-authored a new comprehensive history of the World Health Organization, looking at how world politics have shaped the institution and its mission. (University of Rochester photo / Richard Baker)

By 1980 the WHO could take substantial credit for ending smallpox, making it the first disease in human history to be eradicated. “A shining moment of international cooperation,” says Brown, who points out that that was no small feat during the Cold War. “The United States and the Soviet Union would still be bickering with one another about international treaties, nuclear weapons and chemical weapons, but somehow in the health domain they were able to work together.”

The organization also developed uniform metrics, methods, and measures to deal with international health crises and pandemics. The result were standardized interventions, the gathering of epidemiological intelligence, and the means to evaluate the efficacy of programs.

Some of the most successful WHO programs led to access to essential drugs and antiretroviral treatment, childhood immunizations, and the control of tobacco use—often through a vertical approach—the three authors argue. The WHO also pushed for the development of basic, local health systems instead of centralized, top-down interventions—following essentially the ideals of the “horizontalists.”

But most importantly, argues Brown, was the agency’s role in “articulating a vision and creating high aspirational goals, which inspired lots and lots of people.” The WHO’s main goal—health for all, including physical, mental and social wellbeing—was regarded as a fundamental human right. The WHO’s Alma-Ata Declaration in 1978 (now Almaty, Kazakhstan) stands out to Brown as its finest hour because “people perceived that there really was a common human aspirational framework and set of principles for health.”

Failures

The authors point to a shift at the end of the 1980s, when the agency increasingly came under widespread criticism from many sides—health policy experts, international entities such as the World Bank, and specific countries—for its inefficiency, lack of transparency, politicization, and ultimately irrelevance.

University of Rochester professor emeritus of history, Theodore Brown, was invited to this year’s World Health Assembly meeting in Geneva to give a presentation about his new co-authored book at the United Nations Sustainable Development Goals Health Summit in May.

A largely fair criticism—agrees Brown. He argues that the WHO’s both Geneva-based headquarters and regional structure—“often a bureaucratic nightmare” that the US had insisted on at outset of the organization as a “string-pulling control mechanism”—impeded quick and decisive decision-making in crisis situations. That’s one of the reasons for the delayed response to the Ebola epidemic, says Brown.

Moreover, large donor countries, especially the United States, drastically cut contributions to the WHO amid squabbles over the agency’s direction and policy priorities. As a result, it suffered a loss of financial capability and stature, increasingly competing with public and private organizations such as the World Bank and the Bill and Melinda Gates Foundation.

Ultimately, one of the agency’s largest failures, says Brown, was that it “allowed itself to become so politicized. I expected there to be political contamination or intrusion, but I didn’t expect it to be so pervasive,” he admits. Part of the reason was that the United States contributed an outsized portion of the agency’s budget in its early years. That meant that US policymakers believed they were entitled to set policy, says Brown, pitting the US often directly against the Soviet Union.

In later decades, a different set of funders began to assume a large role in the WHO’s direction. Private and public donors brought both benefits and drawbacks, says Brown: “You gain resources, but you lose control and a coherent sense of governance in which those countries and people most in need of help and intervention have the least say in what these interventions should be.” While these partnerships have helped reduce morbidity and mortality, they usually rely on short-term and ultimately limited strategies, write Brown and his co-authors. The loss of truly democratic decision-making marked an unfortunate return to the vertical approach that put technical expertise before local input, argue the authors.

What role does the WHO play today?

 Fast forward to the 2000s. There’s been a surprising resurgence of the WHO, argues Brown. Since the mid-teens of the new century, the agency has regained a certain amount of authority and credibility—among governments and private players alike—very likely “because the world of global health has become so chaotic, and there have been so many competing interests that even those with the big resources realized that there is no way of achieving any kind of uniform consensus about what programs should be initiated,” says Brown. It seems, says Brown, that the “horizontalist” approach is gaining once again a stronger standing, even among the vertically-inclined private players. Essentially, the WHO has become a reinvented place for decision making and ultimately offering legitimacy for programs, Brown argues.

There’s reason to be optimistic, says Brown who favors the horizontal approach: the man who has been selected as the WHO’s newest director general is the first African to hold that position—Tedros Adhanom Ghebreyesus from Ethiopia—marking a conscious shift toward giving greater voice to local interests, away from the large economic and political powerhouses that have thus far largely shaped the organization’s direction.

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