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EDITORIAL |
Theodore M. Brown is with the Department of History and the Department of Community and Preventive Medicine of the University of Rochester, Rochester, NY. Elizabeth Fee is with the History of Medicine Division, National Library of Medicine, National Institutes of Health, Bethesda, Md.
Correspondence: Requests for reprints should be sent to Theodore M. Brown, PhD, Department of History, University of Rochester, Rochester, NY 14627 (e-mail: theodore_brown{at}urmc.rochester.edu).
Mixed in with the rich and varied articles on global health themes in this issue of the Journal are 6 articles based on historical research. Five of the articles originated in the History Working Group of the Joint Learning Initiative (JLI) "Human Resources for Health and Development," a major international policy and planning initiative undertaken by the Rockefeller Foundation and several partners.1 The sixth, by Didier Fassin and Anne-Jeanne Naudé, was submitted independently but fits here nicely along with the other historical articles.2
The purpose of the History Working Group was to contribute to the JLI’s overall objectives by critically reviewing international public health initiatives during the 20th century and uncovering new insights into their successes and failures. Members were urged to illuminate through historical study the motives, context, and local complexity of these international programs. Elizabeth Fee and Marcos Cueto served as cochairs of the group, and Theodore M. Brown was senior advisor. From March 2003 to May 2004 the group held 2 meetings in Bellagio, Italy, planned and prepared papers, and helped to develop the recommendations of the final JLI report.
The 5 JLI contributions in this issue represent current concerns in the historical study of international health. For many years, scholarship in the field focused on the role played by colonial and postcolonial medicine, US philanthropies, and the first international health agencies during the early decades of the 20th century.3–8 Few studies examined developments in international health in the second half of the century. This has begun to change, and the later period is now drawing increased attention from historians, especially because recent decades have been marked by the tense encounter of cultures in the context of international public health, a changing political climate reflecting the vicissitudes of the Cold War, the emergence of neoliberalism, and the boom of economic "globalization."9–12
Marcos Cueto, in "The Origins of Primary Health Care and Selective Primary Health Care," underscores the dynamics of the Cold War in the 1970s as the major contextual source for the World Health Organization’s (WHO’s) 1978 Alma-Ata declaration on primary health care.13 Cueto suggests that shifts in the international power balance between the United States and the Soviet Union, the new assertiveness of recently decolonized developing nations, and the ascent of China as a geopolitical player explain the relative decline of Western technologically based approaches and the rise of comprehensive, grassroots, and socio-political alternatives. The location of the famous meeting at Alma-Ata in Soviet Kazakhstan was itself reflective of the Cold War context and Soviet versus Chinese maneuvering. Given the circumstances, it was no surprise that "selective primary care," the alternative to primary health care promoted by UNICEF, USAID, and other backers, was perceived by some as a staged "counterrevolution."
Socrates Litsios explores other dimensions of the emergence of primary health care as WHO policy in the 1970s. In "The Christian Medical Commission and the Development of WHO’s Primary Health Care Approach,"14 he traces 2 streams of thinking that converged in 1974, when a critical meeting took place in Geneva, Switzerland, between the staff of the Christian Medical Commission (CMC) and senior WHO staff. A few years before, the CMC had begun to refocus on preventive services for communities at large. Working from principles of human rights and distributive justice, CMC leaders deemphasized technical care and gave priority to comprehensive health care as one part of a general plan for the development of society.
Within WHO, Kenneth Newell and Halfdan T. Mahler began to shift attention toward plans for the integration of preventive and curative care. The World Health Assembly in May 1973 adopted a resolution confirming that countries must develop health services suited to their needs and socioeconomic conditions and use an appropriate level of technology. This resolution provided the basis for a close collaboration between the CMC and WHO, cemented by Mahler’s election as director general of WHO and leading ultimately to Alma-Ata.
Sanjoy Bhattacharya turns from intra- and interorganizational dynamics to issues of bureaucratic complexity and resistance in his article, "Uncertain Advances: A Review of the Final Phases of the Smallpox Eradication Program in India, 1960–1980."15 He explores unpublished correspondence to show that varying levels of programmatic commitment and belief, jurisdictional conflicts, and just plain local sabotage often undermined the supposedly smoothly run, carefully orchestrated, and centrally directed campaign. Bhattacharya documents the ways in which WHO headquarters in Geneva, the South East Asia Regional Office in New Delhi, the Indian central government, and local Indian state governments often got in one another’s way and could be brought into efficient operating relationships—for limited periods—only by concerted diplomacy, financial blandishments, and threats of political embarrassment. Bhattacharya thus offers a nuanced account of the final stages of one of the major international health programs in the later 20th century and reminds us that things are rarely as simple as they are sometimes portrayed and that politics and public health are inextricably interwoven.
Stephen J. Kunitz also highlights the inextricable interweaving of politics and public health. In "The Making and Breaking of Federated Yugoslavia, and Its Impact on Health,"16 he traces the formation and fragmentation of the Yugoslav nation, emphasizing the roles of deep-seated ethnic tensions, regional economic disparities, and the devastating inflationary consequences of a calculated turn to the West. According to Kunitz, the eruption of a bloody civil war in 1991 was inevitable, as were the health consequences of the downward economic spiral that led up to it. He shows that in the 1980s, as inflation exploded, the postwar decline in infant mortality stagnated while mortality in the elderly and mortality due to cardiovascular disease increased. Global economics, more than local ethnic conflict, was the real villain in the piece, because the policies of the International Monetary Fund led to forced under-spending on social services and failed to curb inflation, thus leading to deteriorating health and intensifying ethnic antagonisms.
William Muraskin’s article "The Global Alliance for Vaccines and Immunization (GAVI): Is It a New Model for Effective Public Private Cooperation in International Public Health?"17 completes the set of JLI contributions in this issue. Muraskin strongly argues the case that GAVI, created in late 1999, is riddled with substantial and quite possibly fatal flaws that will undermine the success it has thus far enjoyed. He contends that GAVI is an enterprise built on "top-down globalism" and that its promoters in the Gates Foundation, the International Federation of Pharmaceutical Manufacturers Association, the World Bank, and elsewhere push immunization as a nonnegotiable goal. The allies recruited into GAVI by financial inducements are weak allies at best. They have their own priorities and they realize the full extent of the enormously complex problems "on the ground," not least of them the "human capacity problem," which makes it difficult to implement GAVI initiatives in recipient nations. Because of the top-down imposition of the "policy of the month," Muraskin argues, it is difficult to respond to new initiatives without seriously disrupting existing programs and priorities. He suggests that a little humility and a lot more consultation would go a very long way.
What are the take-home lessons of these 5 contributions? First, that international public health efforts are deeply influenced and critically shaped by their political context. Programs cannot be created in a vacuum or applied in isolation. They are of this world and, like it, they constantly change and thus need to be frequently renegotiated. Second, the culture of international health organizations must be acknowledged in order to understand what priorities will emerge at any particular time and which will survive intra- and interagency competition. Programmatic ideas are always contested and rise and fall with shifting political alliances.
Third, ideas are applied in a world governed by administrative and bureaucratic realities. The translation of plans into actual programs requires a great deal of persistence and negotiating skill to make them real and keep them functioning. Fourth, international health initiatives must reckon with deep-seated historical and cultural traditions, local realities, and global forces. All play roles in the success and failure of public health activities, and no success is likely to last forever, especially when the world changes in dramatic ways. Fifth, top-down initiatives cannot expect to succeed without real bottom-up support. Because people at the local level understand how programs need to function to address their particular needs, there can be no simple formula for international public health success. A single agenda or set of priorities cannot suit all circumstances.
Clearly, there is an important role for history in global public health. Studying history carefully and generalizing from its particulars may not necessarily help us avoid repeating the mistakes of the past, but by distilling the lessons of history, we can certainly learn more clearly where we have been and, as a consequence, become more aware of where we are.
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Acknowledgments |
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Accepted for publication July 30, 2004.
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References |
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 TOP References |
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2. Fassin D, Naudé A-J. Plumbism reinvented: childhood lead poisoning in France, 1985–1990. Am J Public Health. 2004;94:1854–1863.
3. Arnold D, ed. Imperial Medicine and Indigenous Societies. Manchester, United Kingdom: Manchester University Press; 1988.
4. Cueto M, ed. Missionaries of Science: The Rockefeller Foundation and Latin America. Bloomington: Indiana University Press; 1994.
5. Farley J. Bilharzia: A History of Imperial Tropical Medicine. New York, NY: Cambridge University Press; 1991.
6. Lyons M. The Colonial Disease: A Social History of Sleeping Sickness in Northern Zaire, 1900–1940. New York, NY: Cambridge University Press; 1992.
7. MacLeod R, Lewis M, eds. Disease, Medicine, and Empire: Perspectives on Western Medicine and the Experience of European Expansion. London, United Kingdom: Routledge; 1988.
8. Weindling P, ed. International Health Organizations and Movements, 1918–1939. New York, NY: Cambridge University Press; 1995.
9. Briggs CL, Mantini-Briggs C. Stories in the Time of Cholera: Racial Profiling During a Medical Nightmare. Berkeley: University of California Press; 2003.
10. Packard RM. "No other logical choice": global malaria eradication and the politics of international health in the post-war era. Parassitologia. 1998;40:217–229.[Medline]
11. Cueto M. El Valor de la Salud: Una Historia de la Organización Panamericana de la Salud. Washington, DC: Pan American Health Organization; in press.
12. Power HJ. Tropical Medicine in the Twentieth Century: A History of the Liverpool School of Tropical Medicine, 1898–1990. New York, NY: Kegan Paul International; 1999.
13. Cueto M. The origins of primary health care and selective primary health care. Am J Public Health. 2004;94:1864–1874.
14. Litsios S. The Christian Medical Commission and the development of the World Health Organization’s primary health care approach. Am J Public Health. 2004;94:1884–1893.
15. Bhattacharya S. Uncertain advances: a review of the final phases of the smallpox eradication program in India, 1960–1980. Am J Public Health. 2004;94:1875–1883.
16. Kunitz SJ. The making and breaking of Yugoslavia and its impact on health. Am J Public Health. 2004;94:1894–1904.
17. Muraskin W. The Global Alliance for Vaccines and Immunization: is it a new model for effective public–private cooperation in international public health? Am J Public Health. 2004;94:1922–1925.
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