Global institutions: the World Health Organization (WHO)

This book is a short and very readable account of the origins and evolution of WHO as the United Nations specialized agency for global health. It will be of interest not only to scholars and practitioners of public health, but also to those interested in development and international relations. Starting with a brief review of the history of international cooperation aimed at prevention and control of the spread of communicable diseases across borders, the book traces the rise of social medicine and public health in response to recognition of social and economic determinants of the health of populations during the Industrial Revolution in Europe and subsequently into the 20th century on both sides of the Atlantic. Biomedical and social concepts of human health have led to tensions with regard to defining the scope and limits of public health and its amenability to scientific and technical or social and political action. The book discusses these tensions in relation to the foundation of WHO in the aftermath of the Second World War, starting with a definition of its mandate and constitution, which came into force on 7 April 1948. While the constitution adopts a broad notion of health, nevertheless the history of WHO in the subsequent 60 years reveals alternating and competing cycles that reflect ongoing debate and opinions on how best to promote the attainment by all peoples of the highest possible level of health. Following a brief review of the events leading up to WHO’s creation, the book analyses the structure, functions and governance of the Organization, all of which are intended to reflect universal membership as well as its role as the United Nations specialized agency for health. This chapter explains WHO’s unique regional and global structure that enables the Organization to carry out its dual normative and technical cooperation functions, the latter implemented through its 147 country offices. Two chapters are dedicated to analysing WHO’s approaches to competing pressures among its Member States on how best to improve and promote health. These pressures arise from two related dichotomies. The first relates to the relative effectiveness of focusing on specific diseases versus strengthening health systems. The second relates to the balance between focus on health and the health sector versus broader determinants of health and the need for health in all policies and intersectoral action. A chapter on global campaigns against specific diseases traces WHO action against malaria, smallpox, HIV/AIDS and poliomyelitis. It notes how disease control and eradication campaigns fire the public imagination and attract donors. For many people they epitomize the work of a world health organization. However, the author notes WHO’s mixed record and concludes that global disease campaigns are not in themselves an adequate fulfilment of WHO’s mandate to improve world health. A chapter on tackling the broad determinants of health examines attempts by the public health community to influence the work of WHO to better reflect its Constitution. It traces early work that focused on single factors such as water, sanitation, nutrition and housing before moving on to the primary health care movement of the 1970s and 1980s that drew international attention to health equity and the fundamental importance of ensuring universal access to services, including essential medicines. The author records the controversies and political tensions that have accompanied WHO’s work in these areas, including recent work on tobacco control, trade and health and prevention of chronic diseases in which strong vested interests have sought to oppose and undermine the work of the Organization. The final chapter describes pressure on WHO to respond to the realities of globalization by engaging with new stakeholders, beyond its member states, and addressing important cross-border health determinants. The author examines the pressures on the secretariat to embrace global health and the ensuing challenges to revisit WHO’s mandate, basic functions and even its underlying value system. In line with the higher-than-ever priority that has been accorded to public health in international affairs, WHO’s functions and governance have been the subject of repeated studies and calls for reform since the early 1990s. The book concludes that politics has been embedded in WHO throughout its history and is an obvious feature of an international organization mandated to promote the attainment of the highest possible level of health for all peoples. In that context, it is remarkably current at this juncture when human health and wellbeing face challenges as great as any since the Organization was established. ■