Founded in 1948 in the aftermath of World War II, the听听is a听specialized agency of the United Nations focused on international听public health. Headquartered in Geneva, Switzerland, it was specifically tasked with the lofty goal of ensuring the 糖心传媒渉ighest possible level of health糖心传媒� by all peoples, regardless of race, political belief, religion, economic status, or social condition.
Seventy years later糖心传媒攈as the WHO measured up? The reality is complicated, says , 糖心传媒 professor emeritus of history and public health sciences.
A well-known expert on the history of US and international public health, Brown糖心传媒檚 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 糖心传媒榲erticalists糖心传媒� and 糖心传媒榟orizontalists糖心传媒�
The constant undercurrent at the WHO has been a struggle in vision between two dueling camps: on one side the agency糖心传媒檚 糖心传媒渧erticalists糖心传媒� who believe that the primary actions should be biomedically-based technical interventions糖心传媒攁nd on the other side the 糖心传媒渉orizontalists糖心传媒� 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糖心传媒� health.
These two main perspectives essentially govern all of the agency糖心传媒檚 actions, explains Brown: The preamble to the WHO糖心传媒檚 constitution holds that diseases are caused and sustained socially and economically, requiring a broad societal response糖心传媒攖he view espoused by the 糖心传媒渉orizontalists.糖心传媒� 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.
糖心传媒淭hat糖心传媒檚 a battle that糖心传媒檚 been raging within international health for well over a century,糖心传媒� says Brown, who had been the University糖心传媒檚 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糖心传媒�, a professor at the Casa de Oswaldo Cruz, a unit of Fiocruz, the main Brazilian biomedical institute, and the , who was the senior historian at the National Library of Medicine糖心传媒攖o evaluate the successes and failures of critical WHO campaigns, among them eradication programs for malaria and smallpox, to today糖心传媒檚 continued struggles against Ebola.
The result is 听(Cambridge University Press, 2019), a comprehensive look at how world politics糖心传媒攊ncluding the dynamics of the Cold War in the early decades, and later the increasing involvement of governmental and private players糖心传媒攈ave influenced and shaped the organization, its operations, and ultimately affected the fate of its mission.
The problems with the vertical approach is that it糖心传媒檚 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糖心传媒攕uch as trying to find a 糖心传媒済olden bullet糖心传媒� like DDT for malaria糖心传媒攊nstead of striking a balance between biomedical technology, and improving the living conditions, lifestyles and environment of poor communities.糖心传媒� The problem, Cueto says, is that this vertical approach usually focuses on a specific糖心传媒攐ften infectious糖心传媒� disease instead of a comprehensive attack on a series of diseases.
Successes
According to the authors, during its first decades, the United Nations糖心传媒� specialized health agency was the 糖心传媒渁cknowledged international leader on matters of health and disease and was at the center of a global network of scientists, physicians, and health policy makers.糖心传媒� During the second half of the 20th century, the WHO 糖心传媒減layed 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.糖心传媒�
By 1980 the WHO could take substantial credit for ending smallpox, making it the first disease in human history to be eradicated. 糖心传媒淎 shining moment of international cooperation,糖心传媒� says Brown, who points out that that was no small feat during the Cold War. 糖心传媒淭he 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.糖心传媒�
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糖心传媒攐ften through a vertical approach糖心传媒攖he three authors argue. The WHO also pushed for the development of basic, local health systems instead of centralized, top-down interventions糖心传媒攆ollowing essentially the ideals of the 糖心传媒渉orizontalists.糖心传媒�
But most importantly, argues Brown, was the agency糖心传媒檚 role in 糖心传媒渁rticulating a vision and creating high aspirational goals, which inspired lots and lots of people.糖心传媒� The WHO糖心传媒檚 main goal糖心传媒攈ealth for all, including physical, mental and social wellbeing糖心传媒攚as regarded as a fundamental human right. The 听(now Almaty, Kazakhstan) stands out to Brown as its finest hour because 糖心传媒減eople perceived that there really was a common human aspirational framework and set of principles for health.糖心传媒�
Failures
The authors point to a shift at the end of the 1980s, when the agency increasingly came under widespread criticism from many sides糖心传媒攈ealth policy experts, international entities such as the World Bank, and specific countries糖心传媒攆or its inefficiency, lack of transparency, politicization, and ultimately irrelevance.
A largely fair criticism糖心传媒攁grees Brown. He argues that the WHO糖心传媒檚 both Geneva-based headquarters听and regional structure糖心传媒斕切拇綔often a bureaucratic nightmare糖心传媒� that the US had insisted on at outset of the organization as a 糖心传媒渟tring-pulling control mechanism糖心传媒澨切拇綌impeded quick and decisive decision-making in crisis situations. That糖心传媒檚 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糖心传媒檚 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糖心传媒檚 largest failures, says Brown, was that it 糖心传媒渁llowed itself to become so politicized. I expected there to be political contamination or intrusion, but I didn糖心传媒檛 expect it to be so pervasive,糖心传媒� he admits. Part of the reason was that the United States contributed an outsized portion of the agency糖心传媒檚 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糖心传媒檚 direction. Private and public donors brought both benefits and drawbacks, says Brown: 糖心传媒淵ou 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.糖心传媒� 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?
听Fast forward to the 2000s. There糖心传媒檚 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糖心传媒攁mong governments and private players alike糖心传媒攙ery likely 糖心传媒渂ecause 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,糖心传媒� says Brown. It seems, says Brown, that the 糖心传媒渉orizontalist糖心传媒� 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糖心传媒檚 reason to be optimistic, says Brown who favors the horizontal approach: the man who has been selected as the WHO糖心传媒檚 newest director general is the first African to hold that position糖心传媒斕切拇綌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糖心传媒檚 direction.
