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The evolution and development of international health collaboration Jolly, Jennifer Elaine 1987

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THE EVOLUTION AND DEVELOPMENT  OF  INTERNATIONAL HEALTH COLLABORATION By Jennifer Elaine  Jolly  B . A . ( H o n s . ) , Queen's U n i v e r s i t y ,  1986  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS  FOR THE DEGREE OF  MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department o f P o l i t i c a l  We a c c e p t  this  thesis  to the required  THE  as  Science  conforming  standard  UNIVERSITY OF BRITISH October  COLUMBIA  1987  t£} J e n n i f e r E l a i n e  Jolly,  1987  In  presenting  degree  at  this  the  thesis in  partial  University of  fulfilment  of  British Columbia, I agree  freely available for reference and study. I further copying  of  department  this or  publication of  thesis for by  his  or  her  representatives.  that the  for  an advanced  Library shall make  It  is  granted  by the  understood  that  it  extensive  head  of  copying  my or  this thesis for financial gain shall not be allowed without my written  P o l i t i c a l Science  The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date  requirements  agree that permission for  scholarly purposes may be  permission.  Department of  the  October 14,  1987.  ii ABSTRACT The  g o a l of t h i s t h e s i s i s to document and  evolution  and  collaboration. initial  development Utilizing  international  international  development of the  through the  of  e a r l y sanitary  health  conferences.  of  the  The  the  regime i s traced establishment  of  i s then documented, along  transformation t h i s e n t a i l e d  collaboration.  The  the  health  r e l a t i o n s theory,  regulatory  international health organizations with the  explain  in international  health  r e s u l t i n g e f f e c t the i n s t i t u t i o n a l i z a t i o n  international  health  regime had  upon  international  health c o l l a b o r a t i o n i s f i n a l l y presented. It  is  determined  that  states  initial  interest  in  i n t e r n a t i o n a l h e a l t h c o l l a b o r a t i o n grew out of a concern f o r reducing the that  impediments to  quarantine  measures  international imposed.  first,  i n t e r n a t i o n a l c o o p e r a t i o n i n t h i s area expanded.  formed  influence  of j o i n t t e c h n i c a l  international  characteristics  of  scientific  at  increased,  benefits  as  were,  to  the  but  States  commerce  reluctant  Realizing  collaborate,  trade and  cooperation,  organizations.  international  health  knowledge  The under the  of m e d i c a l s p e c i a l i s t s were to cause an  states  special guiding evolution  within t h i s regime. Collaboration  i n t h i s area has  greatly  increased.  The  primary concern of the i n t e r n a t i o n a l health regime i s no longer the  containment of p e s t i l e n t d i s e a s e s w i t h o u t s i g n i f i c a n t  iii i n t e r f e r e n c e t o i n t e r n a t i o n a l commerce. concerned states,  with  improving  regardless  i n t e r e s t s of the  of  the  the  level  of  T h i s regime i s health  e f f e c t s t h i s might  developed states.  Technical  care to a l l have on  the  cooperation  and  aid to developing countries  i s now  World H e a l t h O r g a n i z a t i o n .  T h i s e v o l u t i o n has not  without  some d e g r e e o f  conflict,  now  the c e n t r a l focus of  however, as  d e v e l o p i n g s t a t e s and the m e d i c a l e l i t e s of the  the  occurred i t is  the  organization  have forced the evolution of the previous norms of t h i s regime. The  developing  assistance  states  have  a  clear  interest  in  securing  i n developing t h e i r health i n f r a s t r u c t u r e s , and  e l i t i e s of the WHO  the  are committed by nature of t h e i r s c i e n t i f i c  t r a i n i n g to work towards t h i s i d e a l .  The  developed states  are  not i n f a v o u r of t h i s change as i t t h r e a t e n s t h e i r i n t e r e s t s and  power w i t h i n t h i s regime.  Although i t i n i t i a l l y  appeared  t h a t c o l l a b o r a t i o n i n t h i s area would be r e l a t i v e l y easy t o secure as an improvement i n h e a l t h would be t o every s t a t e ' s b e n e f i t , t h i s has  not always been the case.  r e l a t i o n s theory i s u t i l i z e d o r i g i n s , the o b s t a c l e s , w i t h i n t h i s regime.  and  International  i n t h i s t h e s i s to explain  the e v o l u t i o n t h a t has  the  occurred  TABLE OF CONTENTS Abstract Acknowledgements Introduction  - The P o l i t i c a l Aspects of the Evolution of International Health Collaboration. Endnotes - Introduction.  Chapter One  - T h e o r e t i c a l Framework - The Development of International Health Collaboration. Realism. Neo-Realism or S t r u c t u r a l Realism. Liberalism. Functionalism. Endnotes - Chapter One.  Chapter Two  - The E a r l y Sanitary Conferences - The I n i t i a l Development of the Health Regime. Introduction and S c i e n t i f i c Background. The F i r s t International Sanitary Conference. The Second Conference. The T h i r d Conference. The Fourth Conference. The F i f t h Conference. The Sixth Conference. The Seventh Conference. The Eigth Conference. The Ninth Conference. The Tenth Conference. The Eleventh Conference. Conclusions - The E a r l y Conferences. Endnotes - Chapter Two.  Chapter Three- The I n s t i t u t i o n a l i z a t i o n of the International Health Regime — The Establishment of International Health Organizations. Organization International d'Hygine Publicrue. Twelfth International Sanitary Conference. The E f f e c t s of World War One on International Health C o l l a b o r a t i o n . D i f f i c u l t i e s i n International Health Collaboration - I n s t i t u t i o n a l Loyalty. The Health Organization of the League of Nations. Thirteenth I n t e r n a t i n a l Sanitary Conference. The E f f e c t s of The Second World War on International Health C o l l a b o r a t i o n . Post War Health Collaboration - The U N R e l i e f and R e h a b i l i t a t i o n Administration. Origins of the World Health Organization. Endnotes - Chapter Three.  V  Chapter Four - The World Health Organization and the Evolution of the International Health Regime. 83 Introduction and Epidemiological Review. 83 Programs of Disease E r a d i c a t i o n . 86 The International Health Regime - The Issue of Sanitary Regulations. 89 Non-Compliance and the Sanitary Regulations. 95 Evolution within the WHO. 103 Conclusions - Why The Evolution ? Ill Endnotes - Chapter Four. 115 Conclusion  -  Bibliography Interviews  The Development and Evolution of International Health C o l l a b o r a t i o n . The Evolution of the Health Regime. Obstacles to International Health Collaboration. International Relations Theory and International Health C o l l a b o r a t i o n . Realism. Liberalism. Functionalism. F i n a l Comments - Prognosis f o r the Future of International Health C o l l a b o r a t i o n . Endnotes - Conclusion.  118 118 121 128 129 135 138 141 144 145 149  vi ACKNOWLEDGEMENTS As I r e f l e c t back over the p a s t f o u r months I r e a l i z e t h a t the c o m p l e t i o n o f t h i s t h e s i s would not have been p o s s i b l e w i t h o u t t h e a s s i s t a n c e o f s e v e r a l i n d i v i d u a l s . As t h i s w i l l p r o b a b l y be t h e o n l y chance I w i l l ever g e t t o do t h i s s o r t o f t h i n g , I would l i k e t o take t h i s o p p o r t u n i t y t o thank everybody, even i f i t w i l l prove t o be a b i t s e n t i m e n t a l a t times. F i r s t o f a l l , my a p p r e c i a t i o n i s extended t o a l l those i n d i v i d u a l s who g r a n t e d me an i n t e r v i e w f o r t h e r e s e a r c h of t h i s t h e s i s . Their names are too numerous t o mention here, but can be located i n the Bibliography. I wish t o e s p e c i a l l y thank Dr. Maureen Law, Deputy M i n i s t e r o f H e a l t h and W e l f a r e f o r t a k i n g t i m e out o f h e r busy s c h e d u l e t o i n f o r m me of c u r r e n t developments w i t h i n the WHO. I a l s o have t o acknowledge t h e c o n s t a n t support t h a t my mother and f a m i l y have extended t o me d u r i n g t h i s sometimes t r y i n g endevour. Friends i n Vancouver also must be mentioned f o r a l t e r n a t e l y encouraging, or d i s t r a c t i n g , me from t h i s task. Shannon, Charles, Michelle, Francis, Martin (who was endlessly explaining the d i f f e r e n c e s between r e a l i s m and neo-realism) and Juanita, I w i l l miss you a l l . Gratitude must also be expressed t o Nancy Mina who, i n the m i d s t o f my upheaval from one end o f the c i t y t o another, found me an o f f i c e i n which t h e l a t t e r p a r t o f t h i s t h e s i s was completed. My f r i e n d s , M i c h e l l e , Don, and Lynn a l s o deserve mention and thanks f o r p r o v i d i n g me w i t h a p l a c e t o s l e e p a t times during the l a s t troubled months of t h i s odyessy. F i n a l l y , I wish t o thank t h e members o f my committe f o r t h e i r h e l p f u l s u g g e s t i o n s and c r i t i c i s m s . T h i s t h e s i s would not have been completed w i t h i n t h e d e a d l i n e w i t h o u t t h e sometimes f r i g h t e n i n g counsel o f P r o f e s s o r Mark Zacher who o r i g i n a l l y proposed t h i s topic. My deep appreciation i s also extended t o my t h e s i s a d v i s o r , P r o f e s s o r Don Munton, who not o n l y e d i t e d and p r o v i d e d suggestions that significantly improved t h i s t h e s i s , but also enabled me t o complete i t with some degree of my sanity i n t a c t .  1 INTRODUCTION THE  POLITICAL ASPECTS OF THE EVOLUTION OF INTERNATIONAL HEALTH COLLABORATION  Before the modern age of s c i e n t i f i c knowledge, p e s t i l e n t d i s e a s e s were thought t o be the punishment of t h e Gods. not  until  i t was  realized  that epidemic  I t was  diseases  were  transmitted through human contact that h e a l t h care and disease prevention  became  an  international  issue,  as these  were  problems t h a t c r o s s e d n a t i o n a l boundaries and j u r i s d i c t i o n . Originally,  the method most commonly employed t o contend  the  of epidemic  spread  disease  was  quarantine,  with  w i t h the  e a r l i e s t example occurring i n 532 AD when the Emperor J u s t i n e of  Constantinople i n s t i t u t e d  epidemic. however, maritime  1  Widespread until  later  city-state  use  i t t o combat the g r e a t of quarantine  i n the f i f t e e n t h  of Venice  instituted  d i d not  century,  Plague occur,  when the  a quarantine  where  persons or goods were t o be i s o l a t e d , i n a r e s t r i c t e d location, for  a s p e c i f i c p e r i o d of time,  b e l i e v e d t o be equal t o the  i n c u b a t i o n p e r i o d f o r the d i s e a s e . T h i s was t o be the model, being  quickly  instituted  by o t h e r European n a t i o n s .  Soon  a f t e r , b i l l s of health were inaugarated, although they d i d not come i n t o g e n e r a l use u n t i l 1665.  2  Issued by the c o u n t r y of  d e s t i n a t i o n ' s c o n s u l , they were designed t o prove t h a t as of the  last  disease,  port  of c a l l ,  t h e suspected  s h i p was  free  from  thus f r e e i n g a ship from a lengthy quarantine period.  Quarantine  regulations varied  from  s t a t e t o s t a t e and  2  bills  o f h e a l t h were f r e q u e n t l y s u b j e c t t o b r i b e r y and  corruption. passengers  These  3  and  incidents  caused  great  inconvience to  considerable f i n a n c i a l l o s s t o t r a d i n g nations.  F i n a n c i a l r e p e r c u s s i o n s were soon t o become acute w i t h the first in  e f f e c t s of the I n d u s t r i a l Revolution beginning t o appear  the ninteenth  century.  Trade  had r a p i d l y  f a c i l i t a t e d by t h e development o f t h e steamship  increased, i n 1810, and  the common u t i l i z a t i o n of r a i l transport as of 183 0.  Mounting  p r e s s u r e from these f i n a n c i a l l o s s e s would f i n a l l y t o f o r c e states  t o convene  meetings  i n an e f f o r t  to solve the  obstruction that quarantines and b i l l s of health were posing to trade a t the i n t e r n a t i o n a l l e v e l . I n i t i a l l y , various proposals were made with regards t o the c o o r d i n a t i o n o f q u a r a n t i n e measures along the Although  Mediterranean.  an i n t e r n a t i o n a l c o n f e r e n c e was f i r s t  proposed by  France i n 1834, i t was not u n t i l 1851 that the European nations f i n a l l y agreed t o assemble t o discuss t h i s i n t e r n a t i o n a l issue. Another f a c t o r t h a t prompted t h i s c o n f e r e n c e was t h e C h o l e r a epidemic  t h a t ravaged Europe between 1828 and 1831,  causing  s t a t e s t o adopt s t r i c t e r and thus, more e c o n o m i c a l l y c o s t l y quarantine  measures.  international  A t t h e same  conferences  time  several  other  were o c c u r r i n g t o d i s c u s s other  h i g h l y t e c h n i c a l issues that crossed n a t i o n a l boundaries,  such  as t h e ones t h a t l e d t o t h e c r e a t i o n o f t h e I n t e r n a t i o n a l Postal and Telegraphic Union. It  was, however, the f i n a n c i a l pressures that quarantine  3  measures were p l a c i n g upon growing trade that f i n a l l y provided the impetus that r e s u l t e d i n the f i r s t i n t e r n a t i o n a l a c t i o n to address  t h i s common problem.  As w e l l , t h e i n c r e a s e i n the  numbers o f people a t t e n d i n g t h e Mecca p i l g r i m a g e had g r e a t l y contributed  t o the spread  immigration  of c h o l e r a t o Europe  t o t h e Americas,  and by  when i t had p r e v i o u s l y been  r e l a t i v e l y contained i n India and the East.  4  Countries weighed t h e i r p a r t i c i a t i o n i n such a conference against t h e i r national interest.  Those w i t h t h e g r e a t e s t  amount o f t r a d e , s u f f e r i n g t h e most from q u a r a n t i n e , consequently  t h e most  i n favour  were  o f t h e r e g u l a t i o n and  l i m i t a t i o n o f these damaging measures.  European s t a t e s a l s o  wanted  from  to protect  diseases.  their  populations  T h e r e was, however,  these  a distinct  ravaging  geographical  determination to those countries i n favour of g r e a t l y l i m i t i n g the use o f q u a r a n t i n e and those t h a t c o n s i d e r e d i t v i t a l t h a t these measures remained i n p l a c e .  The Southern  c o u n t r i e s on  the  city-states,  A u s t r i a and  Mediterreanean,  the I t a l i a n  Southern France, were c l o s e r t o t h e source o f epidemics, and were the most supportive of quarantine.  The Northern states of  Europe, e s p e c i a l l y Great B r i t a i n , who, due t o geography, were l e s s a f f e c t e d by t h e c h o l e r a epidemic greater f i n a n c i a l  i n t e r e s t s i n t r a d e , were anxious  removal of a l l unecessary Quarantine protect  and, had i n g e n e r a l , f o r the  impediments to trade.  measures were v e r y much a European d e v i c e t o  the developed  or  "civilized"  countries  from  4  c o n t a m i n a t i o n by the "barbarous" and underdeveloped n a t i o n s . Gradually,  and as a r e s u l t of increased s c i e n t i f i c and  medical  knowledge regarding the e t i o l o g i e s of these epidemic diseases, it  was  realized  t h a t the  cordon s a n i t a i r e approach to  the  prevention of the spread of disease was  not only s c i e n t i f i c a l l y  misguided, but a l s o f i n a n c i a l l y c o s t l y .  As knowledge of how  combat  these  international health  epidemic  diseases  c o l l a b o r a t i o n and  increased,  the  to  i t encouraged  c r e a t i o n of i n t e r n a t i o n a l  organizations.  As a r e s u l t of i n t e r n a t i o n a l c o l l a b o r a t i o n i n t h i s area, a health  regulatory  r e g i m e was  eventually  coordinate the various quarantine A regime may rules  and  to  measures and b i l l s of health.  be d e f i n e d s i m p l y as a s e t o f p r i n c i p l e s , norms, decision  expectations pointed  established  out  making  procedures  around  converge i n a g i v e n i s s u e a r e a .  5  which  actor  I t should  be  t h a t regimes r e f e r t o v o l u n t a r y c o l l a b o r a t i v e  v e n t u r e s undertaken by  independent n a t i o n  states.  As  the  i n t e r n a t i o n a l system remains anarchical, with no supreme power, regimes have no power to enforce t h e i r codes or regulations. A s t a t e i s then f r e e to v i o l a t e the only motivation  i n t e r n a t i o n a l regulatory codes;  f o r a state's compliance with a regulatory  regime's p r o v i s i o n s i s to gain some item that i t cannot  secure  independently. In the case h e a l t h the r e g u l a t o r y regime preceeded establishment  of an i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n .  the When  the Seventh I n t e r n a t i o n a l S a n i t a r y Conference r e s u l t e d i n a  5  s u c c e s s f u l c o n v e n t i o n i n 1893,  t h i s regime came i n t o being.  I t s p r i n c i p l e s were: the regulation of i n t e r n a t i o n a l trade t r a v e l w i t h r e g a r d s t o the p r e v e n t i o n while ensuring  of e p i d e m i c  and  diseases,  a minimum of interference to these commercial  activities.  The  health  regime was  t o become more f i r m l y  grounded with the a d d i t i o n of several more Sanitary Conventions over the unified  next  ten  years,  culminating  i n 1903  in a  single  version.  Cooparation i n t h i s regime was regulation,  however.  An  soon to evolve beyond mere  international  I n t e r n a t i o n a l d'Hygiene Publique, was  body,  formed to coordinate  administer  the  agency was  v e r y much a European o r g a n i z a t i o n ,  functions  existing international health  that  l'Office  i t performed g r a d u a l l y  codes.  and This  although  the  grew u n t i l they were  g l o b a l i n scope. With the advent of the League of N a t i o n s i n 1919 growth of i n t e r n a t i o n a l cooperation  and  the  a f t e r the Second World  War,  the r e s p o n s i b i l i t i e s of i n t e r n a t i o n a l health organizations grew tremendously.  The  i n t e r n a t i o n a l system i t s e l f had  also grown  to include those states beyond the borders of Europe and America; i t now  North  encompased many of the l e s s developed states,  whose numbers  were t o  decolonization.  This expansion i n the number of states and  general wars was  increase  destruction that occurred  greatly  i n the  period  as a r e s u l t of the two  of the  great  to lead to an increasing r o l e f o r i n t e r n a t i o n a l health  organizations  such as the  International Red  Cross, the  League  6  of N a t i o n s H e a l t h  Organization,  Nations and the World Health At  the  national  responsibility individual  citizens,  t r a n s f e r e d to the  states  health  and  eventually  this  began t o t a k e  and  well  being  p r i n c i p l e was  and  United  greater of  their  gradually  i n t e r n a t i o n a l l e v e l . I t eventually became a  norm i n i n t e r n a t i o n a l s o c i e t y that health care was each c i t i z e n ,  the  Organization.  level  f o r the  and  f u r t h e r m o r e , t h a t i t was  a right for  the duty of more  advanced nations to help those nations that were l e s s developed or not as w e l l endowed i n h e a l t h r e s o u r c e s . The most expression World  of t h i s s e n t i m e n t  Health  Organization,  concrete  o c c u r s i n the C h a r t e r where i t s s t a t e d  of  the  objective  is  d e c l a r e d t o be "the h i g h e s t a t t a i n m e n t by a l l p e o p l e s of the highest p o s s i b l e l e v e l of h e a l t h " . 6  previous  This i s i n a d d i t i o n to the  norms o f the regime, which were e s t a b l i s h e d by  developed states and imposed on t h e i r colonies. decolonization, successfully  these  challenging  Third the  World  As a r e s u l t of  nations  norms of the  the  have  previous  been health  regime, which e x i s t e d f o r the developed c o u n t r i e s ' b e n e f i t . The World Health Organization has encorporated t h i s new  norm of  primary health care i n v o l v i n g a t r a n s f e r of health resources i n the new 2000.  g l o b a l h e a l t h s t r a t e g y , H e a l t h For A l l by This develoment has not occurred,  the  however, without some  r e s i s t e n c e on the p a r t of both the developed n a t i o n s and i n t e r n a t i o n a l organization  Year  the  itself.  U l t i m a t e l y t h i s t h e s i s w i l l seek to examine and assess the  7  e v o l u t i o n w i t h i n the h e a l t h regime; evolved  i n t h i s area.  how  cooperation  itself  In so doing, i t w i l l be n e c e s s a r y to  f i r s t examine, the c r e a t i o n of the h e a l t h r e g u l a t o r y regime itself,  and  i t s t r a n s i t i o n from the S a n i t a r y Conferences to  today's World H e a l t h O r g a n i z a t i o n .  Then, the e v o l u t i o n t h a t  has occurred w i t h i n t h i s regime w i l l be o u t l i n e d as w e l l as the important f a c t o r s that have shaped t h i s development.  Finally  the o b s t a c l e s t h a t have e x i s t e d and c o n t i n u e t o e x i s t to f u l l cooperation  i n i n t e r n a t i o n a l health w i l l be explored making use  of several theories of i n t e r n a t i o n a l r e l a t i o n s . The the  f i r s t chapter w i l l  evolution  of the  lay the t h e o r e t i c a l groundwork f o r  health  regime.  It w i l l  theories of i n t e r n a t i o n a l r e l a t i o n s , and  outline  show t h e i r  four  relevance  i n e x p l a i n i n g not o n l y the development of the i n t e r n a t i o n a l health  regime,  encountered.  but  The  second  developments of the the establishment  also  the  obstacles  chapter  will  this  process  detail  the  i n t e r n a t i o n a l health regulatory  of- the  s a n i t a r y regulations and  has  initial regime i n  codes.  The  t h i r d chapter traces the further developments i n i n t e r n a t i o n a l health,  from the establishment  of the League of Nations to the  c r e a t i o n of the World Health Organization. is  concerned with presenting  within  the  health  regime  The  fourth chapter  the evolution that has and  within  the  World  occurred Health  Organization.  The conclusion w i l l i n t e r p r e t these developments  and u t i l i z i n g  the applicable theories of i n t e r n a t i o n r e l a t i o n s  e x p l a i n the reasons behind t h i s e v o l u t i o n .  Ultimately,  the  8  obstacles to f u l l i n t e r n a t i o n a l c o l l a b o r a t i o n be assessed,  along with the implications  i n t e r n a t i o n a l action i n t h i s area.  i n t h i s area w i l l  they have f o r future  9 ENDNOTES - INTRODUCTION  1.  N e v i l l e Goodman, I n t e r n a t i o n a l Health Organizations and Their Work, (Baltimore: Williams and Wilkins Co., 1971), p. 29.  2.  Robert Berkov, The World Health Organization: A Study i n Decentralized International Administration, (Geneva: L i b r a i r i e E. Droz, 1957), p. 36.  3.  Goodman, p. 35.  4.  I b i d . , p. 38.  5.  Stephen Krasner, "Introduction" i n I n t e r n a t i o n a l (Ithaca: C o r n e l l U n i v e r s i t y Press, 1983), p. 1.  Regimes,  6.  A r t i c l e I, The C o n s t i t u t i o n o f t h e W o r l d Organization.  Health  10  CHAPTER  ONE  THEORETICAL FRAMEWORK - THE DEVELOPMENT OF INTERNATIONAL HEALTH COLLABORATION From  the  t h e o r i s t s the where one  perspective  of  most  international  relations  i n t e r n a t i o n a l transmission of disease i s an area  would expect i n t e r n a t i o n a l c o l l a b o r a t i o n t o a r i s e  with r e l a t i v e l y few  obstacles,  as disease i s a problem that a l l  n a t i o n s f a c e t o a degree and the c o n t r o l of i t s spread cannot be achieved through the actions of one is believed amongst  that health  states;  an  state alone. As w e l l , i t  i s a r e l a t i v e l y uncontentious  area  of  "low"  politics,  not  issue  generally  thought of as i n v o l v i n g the s e c u r i t y or economic well-being of a state.  When the development of the  regime i s examined, however, one not  occur  as  readily  as  a f f e c t i n g trade and  of  of "high"  even the s e c u r i t y of a nation emergence o f  did  international  International health  impinged upon i s s u e s  In e x a m i n i n g t h e  health  finds that c o l l a b o r a t i o n  some t h e o r i s t s  r e l a t i o n s would have p r e d i c t e d . have i n c r e a s i n g l y  international  issues  politics,  state.  international  health  c o o p e r a t i o n , f o u r main approaches i n i n t e r n a t i o n a l r e l a t i o n s t h e o r y w i l l be particular following: Realism, theories  compared t o e x p l a i n  area  of  Realism,  Liberalism  international Neo-Realsim and  the  intracacies in this  action. or  Functionalism.  They a r e  Modified  Structural  Each one  considers a s p e c i f i c f a c t o r to be the key  the  of  these  explanatory  11 variable  in  occurred.  explaining  Each explains  why  collaboration  has  or  a p a r t i c u l a r aspect of  has  not  international  h e a l t h c o o p e r a t i o n : the v a r i a b l e s r e l e v a n t t o the a c t o r s , l e v e l of s c i e n t i f i c knowledge,  and  the  state of  the  international  health at that time. Realism and Neo-Realism, i t w i l l be shown f o c u s on the d i s a d v a n t a g e s of c o l l a b o r a t i o n , and e x p l a i n states  are u n l i k e l y t o c o l l a b o r a t e ,  collaborative efforts. the  o t h e r hand,  international  or v i o l a t e the terms of  Functionalism and  more o p t i m i s t i c  collaboration;  why  L i b l e r a l i s m are,  i n t h e i r expectations  they p r e d i c t  instances  on for  where  i n t e r n a t i o n a l c o l l a b o r a t i o n i s l i k e l y to occur. Realists  are  concerned  w i t h the  competion  f o r power,  s p e c i f i c a l l y the power of one n a t i o n s t a t e i n r e l a t i o n t o a l l others, as expressed i n both m i l i t a r y and economic terms. Modified  Structural  Realists  propose  that  paramount concern i s f o r t h e i r s e c u r i t y or national rather  than  their  Maintaining the the  nation  power  national  state  relative  to  autonomy and  i s the  key  p o s s i b l i t i e s of i n t e r n a t i o n a l  factor  a l l other  and  eliminate  t o ensure the  autonomy, states.  economic well-being in determining  of the  collaboration.  L i b e r a l s focus on s t a t e s ' concern w i t h n a t i o n a l They want to  states'  impediments to i n t e r n a t i o n a l  c o n t i n u e d growth of n a t i o n a l  wealth. commerce  prosperity.  They would p r e d i c t i n t e r n a t i o n a l c o l l a b o r a t i o n t o occur when impediments t o i n t e r n a t i o n a l commerce are removed and c o l l a b o r a t i o n r e s u l t s i n an increase  i n the wealth of  when  nations.  12 Functionalism  looks  to i n t e r n a t i o n a l  organizations  to gradually  common tasks.  In t h i s manner, war w i l l become both i m p r a t i c a l  and  uneccessary.  collaboration and  will  overlay  technical  According occur with  p o l i t i c a l d i v i s i o n s with  to f u n c t i o n a l i s t s , increased  meaningful  scientific  knowledge  the p a r t i c i p a t i o n of technical e l i t e s i n trans-national  ventures. The detail  above t h e o r i e s  will  now be c o n s i d e r e d  and t h e i r e x p l a n a t o r y v a r i a b l e s  i n greater  f o r international  c o l l a b o r a t i o n w i l l be further explained. REALISM The  t h e o r e t i c a l construct  of realism  dominated t h e study o f i n t e r n a t i o n a l writings  has,  by and l a r g e ,  relations.  From the  o f Thucidydes t o Hans Morgenthau, c e r t a i n e s s e n t i a l  concepts t h a t form t h i s theory's t h e o r e t i c a l base can be seen c o n s i s t e n t l y reappearing i n the works of various r e a l i s t s .  In  g e n e r a l , r e a l i s t s b e l i e v e human n a t u r e t o be b a s i c a l l y e v i l ; human b e i n g s a r e concerned w i t h a c q u i r i n g  as much power and  influence as they p o s s i b l y can f o r themselves. a l s o thought t o be c o n s t a n t :  Human nature i s  t h e r e i s l i t t l e chance o r hope  f o r improvement.  And unlike l i b e r a l theories  relations,  there  i s no b e l i e f i n an u n d e r l y i n g harmony o f  interests.  As t h e r e i s no s u p e r i o r f o r c e imposing o r d e r upon  states, the actions  of i n t e r n a t i o n a l  of human beings and nations w i l l  naturally  come i n t o c o n f l i c t and l e a d t o war as each s t a t e s t r u g g l e s t o acquire power t o protect  i t s e l f or dominate others.  The world  13  of s t a t e s  i s considered  to be  zero-sum: one  another's g a i n i n terms of power and traditional  realist  viewpoint,  The  influence.  best  Morgenthau i n P o l i t i c s Among Nations.  states  dominant a c t o r s effective  act  i n the  method  of  in a  i n the  expressed  by  r a t i o n a l manner and  achieving  foreign  of  a  policy  state's  are  the  f o r c e i s an goals,  p r e v a i l over economic and  determination  Hans  can be summarized as the  i n t e r n a t i o n a l system;  s e c u r i t y issues i n general affairs  T h i s i s the  1  e s s e n t i a l tenets of realism,  following:  state's l o s s i s  and  social  foreign policy.  W i t h i n the i n t e r n a t i o n a l system p o l i t i c a l i n t e g r a t i o n among nations has  only occurred  to a s l i g h t degree and  i s transitory.  As such, transnational actors have l i t t l e or no power of t h e i r own.  2  Recently realism has been modified  to a c e r t a i n extent so  that i t more c l o s e l y corresponds to i n t e r n a t i o n a l developments of the p o s t w o r l d war power,  era.  expressed u l t i m a t e l y  predominant g o a l realists, with  two  i n m i l i t a r y terms,  of a l l s t a t e s .  believe that nation  their  C l a s s i c a l realism  security,  taking  considered t o be  Modern r e a l i s t s ,  3  or  the neo-  states are more concerned today into  account  more than  just  m i l i t a r y power. NEO-REALISM or STRUCTURAL REALISM Neo-realists traditional  or s t r u c t u r a l r e a l i s t s have added to  realist  assumptions  of  human  nature  and  the the  b e h a v i o u r of n a t i o n s t a t e s the concept of the i n t e r n a t i o n a l  14  system.  This  ordering  i s described  principle  is  as  anarchical,  self-help.  A  where the  state's  r e s p o n s i b i l i t y must be t o guarantee i t s own  main  primary  s u r v i v a l i n an  anarchical system with other competing states.  But  as power  i s not the o n l y f a c t o r i n d e f i n i n g s e c u r i t y , t h e r e are other goals that a state must seek to a t t a i n . Economic  considerations  can often be c r u c i a l to the national i n t e r e s t of a state.  Some  s t r u c t u r a l r e a l i s t s b e l i e v e t h a t s t a t e s i n the i n t e r n a t i o n a l system  are  national  growing  i n t e r e s t or  more  interdependent;  that  4  s e c u r i t y depends to  an  a  state's  e x t e n t on i t s  i n t e r a c t i o n s w i t h o t h e r s t a t e s i n m a t t e r s where i n d i v i d u a l a c t i o n cannot lead to an optimal solution. Traditional  or  classical  realism  predicts  c o l l a b o r a t i o n between states; states are considered  little  u n l i k e l y to  c o l l a b o r a t e and w i l l only enter i n t o j o i n t ventures when there i s no p o l i t i c a l c o s t i n terms of a l o s s of power or i n f l u e n c e to  them.  Structural  realism,  i n comparisson  to  classical  r e a l i s m , i s p r i m a r i l y concerned about the s e c u r i t y of s t a t e s w i t h i n the i n t e r n a t i o n a l system.  As such, c o l l a b o r a t i o n i s  l i k e l y t o ensue when a s t a t e ' s s e c u r i t y would be enhanced to any degree w i t h o u t s e r i o u s c o s t s t o another area. of n a t i o n - s t a t e s  i s not  The  seen as b e i n g zero-sum;  states  t r a d e o f f elements of t h e i r n a t i o n a l s e c u r i t y f o r commercial or o t h e r b e n e f i t s . this  i f i t enhances  international  States  As  such,  can  increased  are even l i k e l y to do  their overall position  system.  world  states  are  within likely  the to  15  c o l l a b o r a t e when i n d i v i d u a l a c t i o n does not l e a d t o the b e s t outcome i n terms of n a t i o n a l i n t e r e s t .  States w i l l c o l l a b o r a t e  to avoid a p a r t i c u l a r outcome or to ensure an optimal s o l u t i o n to  a common p r o b l e m .  international effecient  States  5  will  also participate  r e g i m e s t o overcome the  cooperation,  in  b a r r i e r s t o more  as they not only e s t a b l i s h negotiating  frameworks, but also f a c i l i t a t e decision-making  by coordinating  actor expectations and providing high q u a l i t y informations.  6  LIBERALISM Where c l a s s i c a l r e a l i s m ' s e x p e c t a t i o n s of i n t e r n a t i o n a l c o l l a b o r a t i o n i s small, and s t r u c t u r a l r e a l i s m more o p t i m i s t i c , liberalism largely  i s c e r t a i n that increased c o l l a b o r a t i o n w i l l  as  a result  international  of m o d e r n i z a t i o n .  relations  theory  7  This  occur,  school  of  believes that increases i n  c o l l a b o r a t i o n are i n e v i t a b l e as r e l a t i o n s among nation states become more complex and interdependence  amongst them grows.  With the t e c h n i c a l developments of the l a s t c e n t u r y coming f u l l y i n t o f o r c e , t r a d e has grown immensely and s t a t e s have come i n t o g r e a t e r c o n t a c t and c o n f l i c t w i t h one another ever b e f o r e .  than  As a d i r e c t r e s u l t t h i s t h e o r y would argue t h a t  the s t r u c t u r e of i n t e r n a t i o n a l s o c i e t y has changed  completely.  8  The c l a s s i c g o a l s of the r e a l i s t s , power and s e c u r i t y , have been expanded or superceeded by g o a l s of w e a l t h and  welfare.  M a i n t a i n i n g the s e c u r i t y of i t s g e o g r a p h i c a l boundaries  has  become l e s s important  and  f o r s t a t e s than p r o v i d i n g wealth  s o c i a l welfare goals f o r c i t i z e n s ,  states, i n order to provide  16  for  these  new  demands,  have  increasingly  been  forced to  c o l l a b o r a t e with one another, and i n the process, t o surrender some degree o f t h e i r p o l i t i c a l  autonomy. The key d e c i d i n g  f a c t o r i n c o l l a b o r a t i o n i s whether t h i s a c t i o n w i l l r e s u l t i n greater economic p r o s p e r i t y f o r a nation state, which i s valued above a l l else.  States have faced a dilemma:  whether i t was  preferable t o maximize the b e n e f i t s of increased  collaboration  or t o p r e s e r v e p o l i t i c a l autonomy, as t h e b e n e f i t s o f c l o s e economic r e l a t i o n s can be enjoyed only a t the expense of g i v i n g up a c e r t a i n amount o f n a t i o n a l independence o r autonomy i n s e t t i n g and pursuing economic o b j e c t i v e s . Essential  t o the l i b e r a l  9  conception  i n international  r e l a t i o n s i s t h e p h i l o s o p h y o f Adam Smith.  His b e l i e f i n a  harmony  of i n d i v i d u a l s  of i n t e r e s t s  —  that  the actions  f u l f i l l i n g t h e i r own s e l f - i n t e r e s t would r e s u l t i n an increase i n the common good f o r a l l through the a c t i o n of the i n v i s i b l e hand -- forms t h e f o u n d a t i o n o f t h e p o l i t i c a l b e l i e f s o f t h e liberals.  As a consequence o f h i s t h e o r y , l i b e r a l s  believe  t h a t t h e l e s s government r e s t r i c t i o n s and r e g u l a t i o n i n the life  of p r i v a t e i n d i v i d u a l s , the better.  Following  logically  from the above argument, the l e s s r e s t r i c t i o n s that were placed upon i n t e r n a t i o n a l trade,  the greater the return on investment  which would r e s u l t i n a l a r g e r i n c r e a s e  i n wealth f o r a l l  states. According t o l i b e r a l t h e o r i s t s Richard  Cooper and Edward  Morse, s t a t e s a r e no longer concerned s o l e l y w i t h m a z i m i z i n g  17  their security. m i l i t a r y might, and  Instead  of s t r i v i n g  f o r power i n terms of  a state's main i n t e r e s t i s i n economic issues  i n the scope and  f a c i n g states i s how  terms of t r a d e .  The  t r u e problem  now  to keep the manifold b e n e f i t s of extensive  economic intercourse free of c r i p p l i n g r e s t r i c t i o n s ,  while  at  the same time preserving a maximum degree of freedom f o r each nation to pursue i t s l e g i t i m a t e economic o b j e c t i v e s . conundrum  i s the  corresponding  result  of  modernization  forces  --  the  c e n t r a l i z a t i o n of government i n s t i t u t i o n s and  predominance o f domestic g o a l s  over e x t e r n a l ones.  state's  every  wealth  experiences  This  10  increases  and  member  of  the  As  a  society  t h i s improvement, i n t e r n a l demands are made f o r an  expansion of t h i s wealth: "once economic growth reaches h i g h l e v e l s and s i t s as a continuous dynamic process  i n c r e a s i n g the  r e a l w e a l t h of most members of society.... minds [turn] away from those f o r e i g n  p o l i c y g o a l s pursued by r u l i n g e l i t e s of  monarchical  and  Europe  toward  the  f u r t h e r development  d o m e s t i c w e a l t h through d o m e s t i c means and conditions."  1 1  States  are,  therefore,  under  willing  of  peaceful  to give  up  p o l i t i c a l autonomy and s o v e r e i g n t y to a c h i e v e t h e i r economic goals. that  This contradicts the r e a l i s t perspective that maintains states w i l l  strive,  above a l l e l s e t o m a i n t a i n  their  p o l i t i c a l autonomy and security. For changed.  L i b e r a l s the The  r o l e of the  traditional  power  nation of  the  s t a t e has state  has  also been  undermined to a c e r t a i n extent by the r e s u l t i n g interdependence  18  of n a t i o n s  conducting  longer  has t o t a l  wealth  i f i t relies  markets.  trade  with  one another.  c o n t r o l over i t s p r o d u c t i v e on o t h e r  states  A s t a t e no c a p a c i t y and  f o r raw m a t e r i a l s o r  Although Cooper and Morse's w r i t i n g s are s p e c i f i c to  the post World War Two era, the developments of modernization forces had t h e i r beginnings i n the t e c h n o l o g i c a l advancements and trade l i b e r a l i z a t i o n movements of the ninteenth  century.  FUNCTIONALISM Functionalism, of  the underlying  as espoused by David Mitrany, assumptions  of the l i b e r a l s  c r i t i c i s m s o f t h e r e a l i s t view o f t h e world. belief  i n t h e goodness  o f human nature  interests u l t i m a t e l y guiding  shares many and t h e i r  Present  i sa  and a harmony o f  human a c t i o n .  Mitrany  also  b e l i e v e s that the nation state, constantly s t r i v i n g f o r power and  security,  situation  i s t h e cause  o f war.  i s f o r the t r a d i t i o n a l  superceeded  by s u p r a n a t i o n a l  H i s remedy  for this  form o f government t o be functional  organizations.  Designed t o p r o v i d e h i g h l y t e c h n i c a l f u n c t i o n s t h a t c o u l d no longer  be performed e f f i c i e n t l y o r e f f e c t i v e l y by n a t i o n a l  governments, these  organizations would gradually grow i n scope  u n t i l a web of interdependence would l i n k the i n t e r e s t s of a l l c o u n t r i e s , c a u s i n g an end not only t o war, but e v e n t u a l l y t o the nation-state i t s e l f :  "functionalism overlays the p o l i t i c a l  d i v i s i o n s with a spreading  web of i n t e r n a t i o n a l a c t i v i t i e s and  a g e n c i e s i n which and through which t h e i n t e r e s t s and l i f e o f a l l nations would be gradually i n t e g r a t e d . "  12  / 19  According to functionalism,  a key f a c t o r i n d e t e r m i n i n g  the p o s s i b i l i t i e s of i n t e r n a t i i o n a l c o l l a b o r a t i o n i s the degree of  technical  requires the  s p e c i a l i z a t i o n that  a transnational  before i t can be s u c c e s s f u l l y r e s o l v e d .  roles  of the s c i e n t i f i c  international  elites  who  i n s t i t u t i o n s a r e important.  13  problem  For Mitrany  manage  these  He assumes t h a t  t e c h n i c a l s p e c i a l i s t s share common knowledge and approaches and w i l l put aside t h e i r p o l i t i c a l l o y a l t i e s t o perform t h e i r tasks i n i n t e r n a t i o n a l i n s t i t u t i o n s f o r t h e b e t t e r m e n t o f a l l , not s i m p l y f o r t h e sake o f t h e i r own c o u n t r y . political the  overtones t o i n t e r n a t i o n a l  nature of s c i e n t i f i c  highly  elites.  1 4  There w i l l be no  collaboration This  i s a r e s u l t o f the  s p e c i a l i z e d t r a i n i n g t e c h n i c a l e l i t e s share; they speak  a common s c i e n t i f i c concepts, goals.  l a n g u a g e , have been t a u g h t  and s t r i v e f o r i m p a r t i a l i t y i n achieving  Further, these t e c h n i c a l  capable  Collaboration  of  learning  a d i f f e r e n t perspective cooperation  certain  15  In so doing  According t o Mitrany, humans  from  their  w i l l i n time beget further  Each of these theories  of  scientific  lessons of t e c h n i c a l cooperation i n one i n t e r n a t i o n a l area  w i l l s p i l l o v e r to other a r e a s . are  similar  e l i t e s w i l l pass down the  lessons of c o l l a b o r a t i o n to the general public. the  because of  collaborative  mistakes.  collaboration.  of i n t e r n a t i o n a l r e l a t i o n s creates  t o the explanation of the development  i n international  factors  past  as b e i n g  efforts.  health.  Each  highlights  t h e key t o t h e i n s t i g a t i o n o f C l a s s i c a l realism  considers the  20  survival  and  sanctity  of the nation  overwhelming concern o f n a t i o n a l l e a d e r s . collaboration  i n international  achieve i n the f i r s t place.  health  state  This explains  I t further explains  t o cooperate when t h e i r sovereignty or i n t e r e s t s  and Functionalism,  motivations  why s t a t e s ,  of common action  were seen as b e i n g t h r e a t e n e d by i n t e r n a t i o n a l Liberalism  why  was so d i f f i c u l t t o  even though they may recognize the necessity would refuse  t o be t h e  behind  foreign  regulation.  suggesting that t h e i r are other policy  such  as t e c h n i c a l  and  economic factors, add another facet t o the r e a l i s t explanation for  international  collaboration.  I t was t h e c o m m e r c i a l  i n t e r e s t s of states  and t h e i r concern f o r i n c r e a s e d  through  prompted  trade  that  cooperation.  k n o w l e d g e had t o be a d v a n c e d t o a c e r t a i n  And  wealth  scientific  stage  before  c o l l a b o r a t i v e ventures would ensue. The  i n t e r n a t i o n a l health regime has i n f a c t s u b s t a n t i a l l y  changed from i t s o r i g i n a l form and i t has had an e f f e c t on the actions  and m o t i v a t i o n s  collaboration  o f i t s members.  have been gradually,  Obstacles to  yet consistently,  removed.  There i s now a much g r e a t e r degree o f c o l l a b o r a t i o n i n t h i s area than b e f o r e .  The reasons f o r t h i s occurence w i l l be  examined i n l i g h t o f t h e i n s i g h t s o f i n t e r n a t i o n a l r e l a t i o n s theory.  The next c h a p t e r w i l l  review t h e o r i g i n s o f t h i s  process, the i n t e r n a t i o n a l sanitary conferences and the i n i t i a l development of the health regime.  21 ENDNOTES - CHAPTER ONE  1.  Hans J . Morgenthau, P o l i t i c s Among N a t i o n s : The S t r u g g l e f o r Power and Peace, F i f t h E d i t i o n , (New York: A l f r e d A. Knoff, 1973), p. 3-5.  2.  Robert Keohane and Joseph Nye, Power and Interdependence, (Boston: L i t t l e , Brown & Co., 1977), p. 23-24.  3.  Morgenthau, p. 27.  4.  Thisdoes not i n c l u d e Kenneth Waltz, who with h i s i n f l u e n t i a l book, The Theory of I n t e r n a t i o n a l Relations i s one of the pioneers of neo-realism. Other neor e a l i s t s , such as Keohane and Nye, f a l l i n t o t h i s category.  5.  Arthur Stein, "Coordination and C o l l a b o r a t i o n : Regimes i n an A n a r c h i c World" i n I n t e r n a t i o n a l Regimes, ed. Stephen Krasner, (Ithaca: C o r n e l l U n i v e r s i t y Press, 1983), p. 121126.  6.  Robert Keohane, "The Demand f o r I n t e r n a t i o n a l Regimes" i n International Regimes, ed. Stephen k r a s n e r , (Ithaca: C o r n e l l U n i v e r s i t y Press, 1983), p. 150-155, 160.  7.  As stated by Edward Morse i n Modernization and the Transformation of I n t e r n a t i o n a l Relations, (New York: The Free Press, 1976), p. 8-9. Modernization i s i d e n t i f i e d as the r e s u l t i n g s p e c i a l i z a t i o n , s e l f - s u f f i c i e n c y and l e v e l of c e n t r a l i z a t i o n t h a t becomes c h a r a c t e r i s t i c of s t a t e s after industralization. T h i s caused a r e v o l u t i o n a r y change i n human l i f e : o v e r a l l p o p u l a t i o n expanded as the a v a i l a b l e t e c h n o l o g y and r e s o u r c e s grew t o support more people.  8.  Ibid,  p.  89.  9.  Robert Cooper, The Economics of Interdependence: Economic P o l i c y i n the A t l a n t i c Community, (New York: McGraw H i l l , 1968), p. 4.  10.  Ibid , p. 5.  11.  Morse, p. 80.  12.  David M i t r a n y , A Working Peace Quandrangle Books, 1966), p. 6.  13.  I b i d . , p. 27.  System  (Chicago:  22  14.  I b i d . , p. 39. A l s o see I n i s Claude, Swords i n t o Ploughshares: The Progress and Problems of International O r g a n i z a t i o n , F o u r t h E d i t i o n (New York: Random House, 1971) p. 38.  15.  Mitrany, p. 44.  23  CHAPTER TWO THE EARLY SANITARY CONFERENCES — THE INITIAL DEVELOPMENT OF THE HEALTH REGIME  The h i s t o r y o f t h e e a r l i e r i n t e r n a t i o n a l s a n i t a r y conferences i s one of nations driven t o i n t e r n a t i o n a l n e g o t i a t i o n and r e g u l a t i o n by a common danger, but c o m p l e t e l y unable t o r e a c h agreement because of t h e l i m i t a t i o n s o f s c i e n t i f i c knowledge. — Norman Howard-Jones INTRODUCTION AND SCIENTIFIC BACKGROUND The  h i s t o r y of the I n t e r n a t i o n a l Sanitary  reflects  the h i s t o r y of p u b l i c h e a l t h  perspective —  i n an i n t e r n a t i o n a l  t h e f i r s t movement towards what today i s the  World Health Organization. the  Conferences  historical  progress  This second chapter w i l l document o f European  states  as they  moved  towards i n t e r n a t i o n a l r e g u l a t i o n i n a j o i n t e f f o r t , not only to combat  the spread  of disease,  but a l s o  to lessen the  impediments quarantine measures i n c r e a s i n g l y posed trade.  Despite  to growing  states' w i l l i n g n e s s t o discuss these issues at  the i n t e r n a t i o n a l l e v e l , progress was to come slowly to  this  area. I t was to take seven actual conferences before a l i m i t e d c o n v e n t i o n c o u l d be r a t i f i e d by the n e c e s s a r y c o u n t r i e s . obstacles  t o a g r e e m e n t were, i n p a r t ,  The  due t o a l a c k o f  s c i e n t i f i c knowledge as expressed by the d i f f e r i n g and opposing views on the t r a n s m i s i b i l i t y of p e s t i l e n t diseases. Cholera,  the disease  t h a t caused t h e g r e a t e s t  concern  24 amongst  Europeans,  was  spread  through  human  contact.  Governments r e a c t e d out of f e a r and sought t o impose a cordon s a n i t a i r e between t h e i r n a t i o n s and the a f f e c t e d areas. westward  spread  of t h i s  nineteenth century. of  c h o l e r a was  d i s e a s e had  occurred u n t i l  A s p e c i a l problem c o n t r o l l i n g the  presented  by  the  l a r g e number o f  p a r t i c i p a t i n g i n the Mecca p i l g r i m a g e , most o f t e n  No the  spread people  enduring  crowded and unsanitary conditions during t h e i r voyage and stay. The  q u a r a n t i n e p r a c t i c e s of the day were a r b i t r a r y  and  o f t e n d e s t r u c t i v e , r e s u l t i n g i n c o n s i d e r a b l e damage t o both s h i p s and t h e i r cargo.  Goods were c o n f i s c a t e d , or d e s t r o y e d  and t r a v e l l e r s were subject ot extensive periods of quarantine in  questionable  Clean  bills  quarantine  of  establishments  t h a t were v i r t u a l p r i s o n s .  health,  were n e c e s s a r y  which  to  escape  procedures,  were o f t e n f r a d u l e n t , b e i n g h i g h l y  susceptible to bribery.  Quarantine p r a c t i s e s were based to a  great  extent  on  superstition  s c i e n t i f i c knowledge and protected  by  the  fact.  and  r a t h e r than  on  Countries were i n f a c t best  1  development  hersay,  o f good p u b l i c h e a l t h  and  s a n i t i a t i o n services, which would g r e a t l y reduce the number of cholera attacks.  Unfortunately,  i t was  t o take many years  before the contagions of the major diseases were i d e n t i f i e d and these f a c t s  confirmed.  Opinions concerning the spread of these epidemic were d i v i d e d i n t o two  diseases  main groups, the c o n t a g i o n i s t s ,  b e l i e v e d t h a t d i s e a s e s such as c h o l e r a were spread  who  through  25 direct  human  contact,  and t h e a n t i - c o n t a g i o n i s t s , o r  s a n i t a t i o n i s t s who believed that the causes of cholera l a y i n unsanitary  conditions of the v i c t i m s ' l i v i n g quarters,  production  and s a n i t a t i o n d i s p o s a l .  The B r i t i s h  food  medical  s c i e n t i s t s were proponents of the l a t t e r p o s i t i o n , while most of  the other  countries' physicians  former, c o n t a g i o n i s t e x p l a n a t i o n . position  had much t o do w i t h  found  credence  i n the  Undoubtedly t h e B r i t i s h  their  commercial i n t e r e s t s .  England had the most advanced sanitary system and p u b l i c health care system, as w e l l as being geographically removed source o f t h e spread  from the  o f e p i d e m i c s , t h e M i d d l e East.  As a  consequence, B r i t a i n was f a r l e s s a f f e c t e d by t h e s e d i s e a s e s than were British  other European nations. As a n t i - c o n t a g i o n i s t s , the  felt  that quarantine  as they were t o succeed. inspection arrival spread  of ships  They f u r t h e r b e l i e v e d t h a t m e d i c a l  and cargo  were as e f f e c t i v e of disease  as w e l l  commercial  trade.  the  of the B r i t i s h  logic  measures were as l i k e l y t o f a i l  at points  as q u a r a n t i n e as b e i n g  of departure  and  i n preventing the  f a r l e s s damaging t o  Other countries would slowly argument as t h e i r  acknowledge own t r a d i n g  i n t e r e s t s grew. As  well  quarantine,  as t h e growing m e d i c a l c o n t r o v e r s y there  was a l s o p o l i t i c a l  regarding  opposition  to i t s  i m p o s i t i o n on t h e grounds t h a t i t was an i n s t r u m e n t o f s t a t e i n t e r f e r e n c e i n p r i v a t e commerce. Some suspected used f o r a l t e r i o r motives such as espionage.  t h a t i t was  26 In Europe cholera had  only r e c e n t l y appeared i n epidemic  form, p r e v i o u s l y b e i n g c o n f i n e d t o C e n t r a l A s i a and I n d i a . I t was  considered  had  not  a new  experienced  e p i d e m i c two  Gradually,  F i v e c h o l e r a pandemics,  mounting p u b l i c f e a r , s t a t e s q u i c k l y  these obstacles were to force states to consult against  the  common  peril  these  first  Conference was 1834,  2  and  epidemic  posed.  FIRST INTERNATIONAL SANITARY CONFERENCE: PARIS, The  place  on the growing t r a d e of European c o u n t r i e s .  measures  diseases  plague  e x i s i t i n g quarantine p r a c t i s e s which began to  severe p r e s s u r e  devise  the  who  were to s t r i k e Europe over the next f i f t y  As a r e s u l t of  increased  THE  a s i m i l a r s i t u a t i o n since  centuries previously.  b e g i n n i n g i n 1818, years.  and t e r r i f y i n g d i s e a s e t o Europeans  with  proposal  for  an  1851  International  Sanitary  made by the French Sanitary Service as e a r l y as the  Administrative  British  later  difficulties,  and  proposing  one  in  1843.  a f a i l u r e t o agree on i t s  n e c e s s i t y , were t o pre-empt t h i s c o n f e r e n c e f o r s i x t e e n more years.  Landlocked  countries  consequently l e s s a f f e c t e d by  s u c h as  Austria,  the l a s t cholera epidemic  t h a t the i d e a of an i n t e r n a t i o n a l c o n f e r e n c e was When  cholera  century,  reappeared  i t was  First  i n the  1851.  epidemic  Conference was  were felt  premature. wave  3  that  a problem that  solved at the i n t e r n a t i o n a l l e v e l .  International Sanitary  on J u l y 27,  third  f i n a l l y concluded that t h i s was  must be approached and  who  The  convened i n Paris  As the French Foreign M i n i s t e r stated i n h i s  27 opening address t o the c o n f e r e n c e : where  a l l the  industries  of the  " t h i s was  u n i v e r s e seemed  forgotten t h e i r former r i v a l r i e s to j o i n hands" Twelve  c o u n t r i e s attended  [to be] an age  this  to  have  4  conference;  a l l were  European and were r e p r e s e n t e d by both a m e d i c a l d o c t o r and a diplomat, their to  the l a t t e r to represent the commercial  countries.  5  The objective of t h i s  "regulate i n a uniform way  the Mediteranean."  i n t e r e s t s of  f i r s t conference  was  the quarantine and l a z a r a t t o s i n  Yet the debate a t the c o n f e r e n c e was  as  much about epidemiological t h e o r i e s of the diseases between the rival  c o n t a g i o n i s t and s a n i t a t i o n s c h o o l s , as i t was  standardizing quarantine regulations.  This was  about  a pattern to be  repeated at future conferences. The quarantine,  United  Kingdom  was  arguing the i t was  the  s t r o n g e s t opponent  t o t a l l y impotent  the spread of epidemic d i s e a s e s ,  whereas the  of  i n preventing Mediterranen  countries as w e l l as Russia were i n favour of s t r i c t quarnatine measures.  France  was  divided  M e d i t e r r a n e n p o r t s approved  between  i t s r e g i o n s ; the  of s t r i c t q u a r a n t i n e , w h i l e the  Northern ports f e l t i t threatened t h e i r commercial  interests.  6  A f t e r s i x months of debate, f i v e of the t w e l v e c o u n t r i e s had reached agreement on 137 a r t i c l e s that were to form the f i r s t International  S a n i t a r y Code.  T h i s code  was  not  t o be  a  s u c c e s s , however; i t was r a t i f i e d by o n l y t h r e e c o u n t r i e s and two  l a t e r withdrew because of an i n a b i l i t y t o c a r r y out the  requirements.  28 Despite the apparent of  securing a lasting  precedent had  f a i l u r e of t h i s conference  agreement,  i n many respects.  been a g r e e d  i t provided  i n terms  an  important  A number of important  principles  upon, w h i c h w o u l d l a t e r practises.  It  be  embodied i n  international  quarantine  was  agreed  that  q u a r a n t i n e was  not a p p l i c a b l e t o s h i p s w i t h a c l e a n b i l l of  health; that maximum and minimum periods of quarantine were to apply,  differing  for  each  disease  (plaugue,  cholera  and  s m a l l p o x ) ; t h a t l a z a r e t t o s should be h o s p i t a l s , not p r i s o n s , and  that quarantine dues should be uniform and not regarded as  a source of revenue.  7  THE SECOND INTERNATIONAL SANITARY CONFERENCE: PARIS, As the f i r s t Sanitary Conference 1856,  with  remaining  the  withdrawl  was  c l e a r l y a f a i l u r e by  o f P o r t u g a l and  s i g n a t o r y , France, proposed another  c o n f e r e n c e f o r 1859.  1859  S a r d i n i a , the international  I t s o b j e c t i v e was to d r a f t a c o n v e n t i o n  t h a t embodied the p r i n c i p l e s of the f i r s t code t h a t would be acceptable  to  a l l countries.  As  disagreements between the s c i e n t i f i c only diplomatic delegates were sent.  t h e r e had  been  great  experts the time before, This time the  political  unrest of Europe and wide disagreement over the b a s i c aims and elements of the c o n v e n t i o n were t o keep new being  concluded.  recommendations,  Instead, was  views  on  final  draft  contained  only  s i g n e d by the d e l e g a t e s of o n l y e i g h t  c o u n t r i e s , and was promptly Countries'  the  r e g u l a t i o n s from  the  f o r g o t t e n , never t o be utility  of q u a r a n t i n e  ratified. had  not  29 significantly  altered  from  their  stances  at the F i r s t  conference, eight years previously. THE THIRD INTERNATIONAL CONFERENCE: CONSTANTINOPOLE, 1866 In much t h e same way t h a t t h e t h i r d o n s l a u g h t o f c h o l e r a had g a l v a n i z e d t h e European c o u n t r i e s i n t o i n i a t i n g t h e F i r t S a n i t a r y Conference  i n 1951, t h e f o u r t h wave o f t h e c h o l e r a  pandemic p r e c i p i t a t e d t h e t h i r d conference. The d e l e g a t e s o f s i x t e e n c o u n t r i e s met a t Turkey's i n v i t a t i o n origins  of cholera, i t s t r a n s m i s s i b i l i t y  special  p r e v e n t a t i v e measures  with  t o d i s c u s s the  and p r o p o g a t i o n ,  regards  t o t h e Mecca  p i l g r i m a g e such as hygiene, q u a r a n t i n e and d i s i n f e c t i o n , as w e l l as the route the 1865 pandemic had taken.  8  The objective of t h i s conference was t o f i n d an e f f e c t i v e means o f a r r e s t i n g  t h e spread o f c h o l e r a , r a t h e r than the  c o o r d i n a t i o n o f q u a r a n t i n e measures, which had been t h e main concern of the two previous conferences.  The conclusions t h i s  conference came t o were s u p r i s i n g l y accurate, despite the fact that cholera v i b r o would not be s c i e n t i f i c a l l y determined f o r another  seventeen  years.  At t h i s conference delegates agreed  i t was u n l i k e l y that cholera would become endemic i n Europe as it  was  i n India,  along  t h e Ganges R i v e r .  I t was  also  determined that the Mecca Pilgrimages were an important source f o r the spread of t h i s disease, e i t h e r through maritime routes, or a l t e r n a t e l y through  rail.  9  On the b a s i s of the above conclusions, the French proposed the immediate appointment o f a committee  t o c o n s i d e r the  30 i m p o s i t i o n of a ban Arabian  ports  amongst  the  and  an a l l m a r i t i m e communications between Egypt  pilgrims.  i f c h o l e r a was The  a g a i n t o break  chair-elect,  Stuart  of  out  Great  B r i t a i n , moved, however, h i s committee be dissmissed as i t was not y e t determined how  c h o l e r a was  s t a t e d t h a t he c o n s i d e r e d delegate,  transmitted.  He f u r t h e r  i t t o be h i s task, as the  British  to oppose any measures that would cause interference  with trade, unless t h e i r necessity could be p r o v e n .  10  The Asian countries of Turkey and P e r s i a a l s o objected to t h i s measure on the b a s i s t h a t i t v i o l a t e d the s o v e r e i g n t y of the Muslim c o u n t r i e s by imposing the customs, d o c t r i n e s and logic  of  delegates  European  nations  objected  on  the  on  their  subjects.  Other  1 1  grounds t h a t i t would p l a c e  the  p i l g r i m s i n a considerable predicament i f they were forced to return over land, through the desert, or worse, remain i n Mecca indefinitetly. and Spain, who possessed  C o u n t r i e s such as France, P o r t u g a l , P r u s s i a f e l t they had a greater need f o r quarantine  a greater b e l i e f i n i t s efficacy,  urged t h a t  committee proceed with i t s o r i g i n a l task of imposing a ban  and the on  communication between Egypt and other Arabian ports. I t was imposed  f i n a l l y agreed that an o f f i c i a l quarantine would be  i f c h o l e r a d i d a g a i n break out  pilgrimages.  As t h i s convention was  a t the  never signed,  site  of  none of the  p a r t i c i p a n t s were o f f i c i a l l y bound by t h i s c o n c l u s i o n . l a t e r s i g n i f i c a n c e , B r i t i a n had delegates  that:  the  Of  agreed w i t h the r e s t of the  " A s i a t i c cholera, which on various  occasions  31 had t r a v e l l e d throughout the world, has i t s o r i g i n s i n I n d i a , where i t a r i s e s and where i t e x i s t s i n a permanent endemic state."  T h i s p o i n t was  1 2  subsequent  t o be l a t e r d e n i e d by B r i t a i n a t  c o n f e r e n c e s due t o the i m p l i c a t i o n s i t would have  f o r B r i t i s h s h i p s t r a n s v e r s i n g the Suez Canal.  A l r e a d y the  seeds of the l a t e r B r i t i s h p o s i t i o n can be seen, f o r at t h i s c o n f e r e n c e they were not p r e p a r e d t o admit t h a t c h o l e r a was exported from India by ships f l y i n g the B r i t i s h f l a g .  Britain  d i d , however, admit t o h a v i n g a s p e c i a l r e s p o n s i b i l i t y w i t h r e g a r d s t o c o n t r o l l i n g the spread of c h o l e r a from I n d i a , f o r which i t proposed a s e r i e s of sanitary improvements designed to contain t h i s disease. While no c o n v e n t i o n s r e s u l t e d from t h i s conference, i t marked  an  advance  principles  in international  were e s t a b l i s h e d  public  health.  f o r the c o n t r o l  and  c h o l e r a a t the Mecca p i l g r i m a g e s , w i t h emphasis  spread of  p l a c e d upon  the importance of measures being taken before d e p a r t u r e . the  divergent positions  of  many  p r i n c i p l e of quarantine remained  Sound  13  countries regarding  f i r m l y i n evidence.  Yet the  Issues of  national i n t e r e s t prevented states from reaching an agreement. Turkey was prestige  concerned about i t s i n t e r n a t i o n a l r e p u t a i o n , i t s and  political  autonomy.  Great  Britian  had i t s  f i n a n c i a l i n t e r e s t s c l e a r l y i n mind at t h i s conference, o t h e r E u r o p e a n c o u n t r i e s were g e n u i n e l y c o n c e r n e d  and with  a r r e s t i n g the spread of c h o l e r a , r e g a r d l e s s of the n e g a t i v e e f f e c t s t h e i r p r o v i s i o n s would have on other countries.  32 THE  FOURTH INTERNATIONAL SANITARY CONFERENCE: VIENNA, The  by  Fourth  Russia  International Sanitary conference was  i n an  effort  to  gain  relief  from  the  1874 proposed damaging  q u a r a n t i n e r e g u l a t i o n s imposed along the Danube R i v e r . official  The  objective of the twenty-one states that attended t h i s  c o n f e r e n c e was  t o re-examine and c o d i f y the c o n c l u s i o n s  that  were made at the T h i r d Conference, eight years previously. delegates  to t h i s conference were almost a l l medical s c i e n t i s t s  and the debate concerning  the transmission  unabated from previous years. in  the  The  commissions  that  of cholera  continued  This debate can c l e a r l y be seen  were convened  to  prepare  draft  l e g i s l a t i o n f o r the regulation of quarantine i n Europe.  While  i t was  to be  e a s i l y agreed t h a t l a n d quarantine,  considered  "unworkable and consequently useless", should be abolished, s i t u a t i o n was maritime  the  to prove more c o n f r o n t a t i o n a l w i t h r e g a r d s t o  quarantine.  14  O r i g i n a l l y the committe proposed that quarantine should r e p l a c e d by r i g o r o u s m e d i c a l i n s p e c t i o n .  T h i s committee  be was  l a r g e l y composed of Northern European states, and the Southern states, who  were more supportive of quarantine measures, moved  t h a t the committee be asked t o make a f u r t h e r r e p o r t , i n t o account the states  of  taking  "special conditions of quarantine i n c e r t a i n  Southern  Europe".  They  also  requested  that  a d d i t i o n a l members representing these states should be added to the  committee.  decided  that  15  the  While  this  committee's  motion report  was  defeated  should  be  it  revised  was to  33 include both p r i n c i p l e s of quarantine and but that they should being  i n an  knowledge and interest  inspection,  only be recommendations, with each state  f r e e t o choose between the two,  applied  medical  uniform  fashion.  The  as l o n g as they were lack  of  scientific  the c l e a r d i f f e r e n c e s i n the p e r c e i v e d  of Northern and  successful conclusion'of  Southern s t a t e s was  self-  t o prevent a  a sanitary conference f o r twelve more  years. Although t h i s c o n f e r e n c e reached few positive  development  lay  conclusions,  i n i t s proposal  i n t e r n a t i o n a l commission on epidemics.  for a  I t was  one  permanent  declared that  such an i n s t i t u t i o n would be valuable "from the t r i p l e point of view  of  science,  interests."  humanity  Its duties  1 6  epidemics; to present administration  of  were t o  quarantines;  recieved  the by  fact the  that  this  delegates  a l m o s t t h i r t y years.  include  the  material study  to  consult  with  of and  states  topics, and to propose the convening of  international sanitary  Despite  international  reasoned advice on the establishment  regarding the above two future  and  conferences  proposal i t was  I t was  not  was  when necessary. unanimously  t o be  not u n t i l 1907  acted  well  upon f o r  t h a t the O f f i c e  I n t e r n a t i o n a l d'Hygine Publique (OIHP) f i n a l l y came i n t o being. At t h i s time, c e r t a i n governments were r e l u c t a n t t o a c t upon t h i s proposal;  they doubted the use and n e c e s s i t y of such an  organization.  The B r i t i s h , i n p a r t i c u l a r , f e l t t h a t i t would  be of l i t t l e use:  "we  must confess  to want of f a i t h , "  reported  34 the  British  delegate,  "in  the  i n t e r n a t i o n a l s c i e n t i f i c work". proposal  was  value  17  of  co-operative  Despite the  f a c t that t h i s  not w e l l received then, the OIHP d i f f e r e d l i t t l e  from the guidelines established at Vienna i n The  oppostion of the  of h e a l t h  1874.  B r i t i s h to i n t e r n a t i o n a l regulation  concerns must be understood i n r e l a t i o n t o t h e i r  views on the u t i l i t y of q u a r a n t i n e .  As the foremost t r a d i n g  n a t i o n i n the w o r l d a t t h i s time, q u a r a n t i n e had the detrimental  e f f e c t upon B r i t a i n .  conferences often was the  retention  of  greatest  As the mood of i n t e r n a t i o n a l  contrary to B r i t i s h i n t e r e s t s ,  quarantine  i n some form  favouring  or another,  B r i t i s h u s u a l l y found themselves to be i n the minority.  the They  consequently grew more suspicious of the i n t e r n a t i o n a l sanitary conferences,  as  the  measures  they  proposed  would  hamper  B r i t a i n ' s s i g n i f i c a n t commercial i n t e r e s t s . In  the  end,  development of  this  conference  added  international sanitary  little  to  regulations,  the  for i t  f a i l e d t o r e a c h consensus on any of the proposed r e s o l u t i o n s . In f a c t , the f i n a l document, i n approving of both the continued use  of  quarantine  and  also  the  new  method  of  medical  inspections, l e f t countries free to do whatever they wished, as i f the conference had never occurred. little  discussion  of the  ramifications  opened f i v e y e a r s e a r l i e r i n 1869, influence  on  conferences.  the  spread  Suprisingly, there  of  of  the  was  Suez Canal,  t h a t would have a d r a m a t i c  cholera  and  future  sanitary  35 THE  FIFTH INTERNATIONAL SANITARY CONFERENCE: WASHINGTON, 1881 The F i f t h International Sanitary Conference was an anomaly  in  terms  of t h e development  conferences.  and p r o g r e s s i o n  I t had no l o g i c a l  connection  of these  t o e i t h e r the  p r o c e e d i n g o r s u c c e e d i n g c o n f e r e n c e s , and was the o n l y one t o be held o f f the European continent.  I t was held a t the request  of the United States of America t o secure i n t e r n a t i o n a l assent f o r a p i e c e o f American d o m e s t i c l e g i s l a t i o n t h a t o t h e r w i s e would  be u n e n f o r c e a b l e .  1 8  The U n i t e d  States  was g r e a t l y  concerned with c o n t r o l l i n g the spread of cholera and e s p e c i a l l y the spread of y e l l o w f e v e r , a d i s e a s e t h a t was l o c a l i z e d t o the Western Hemisphere. designed  The US Congress had passed an Act i n 1879  "to prevent  the i n t r o d u c t i o n of contagious or  i n f e c t i o u s d i s e a s e s coming from i n f e c t e d p o r t s abroad." provisions  of the a c t required  d e s t i n a t i o n possess a c e r t i f i c a t e  that  a vessel  with  from a US consular  The a US  official  " s e t t i n g f o r t h the sanitary h i s t o r y of s a i d v e s s e l " .  1 9  The  United States believed that a lack of a t t e n t i o n a t the point of departure r e s u l t e d i n the c o s t l y a p p l i c a t i o n of quarantine restrictions  at destinations,  and sought  t o remove  this  unnecessary impediment t o trade. As t h e a c t s t i p u l a t e d t h a t American c o n s u l a r  officials  were r e q u i r e d t o ensure p e r s o n a l l y t h e f a c t s on t h e h e a l t h certificates, nationals.  f o r e i g n s h i p s would have t o be examined by US  Thus, a s h i p c o u l d not embark on i t s voyage i f  bound f o r a US d e s t i n a t i o n u n t i l i t had been boarded i n i t s  36  home p o r t , i n s p e c t e d and g i v e n a c l e a n b i l l agent of a f o r e i g n power. t h i s proposal as i t was  of h e a l t h by  an  O b j e c t i o n s were q u i c k l y r a i s e d t o  regarded as an infringement  of national  s o v e r e i g n t y as w e l l as a v e i l e d c r i t i c i s m on the i n t e g r i t y of foreign sanitary offices. national  systems  particualrly  of  Spain and I t a l y , b e l i e v i n g t h e i r inspection  i n s u l t e d and  charge. Great B r i t a i n ,  to  be  strongly resented  the Netherlands and  i n s t e a d t h a t each country's  adequate, the US's  own felt  implicit  Portugal  suggested  m e d i c a l o f f i c i a l s should be  the  ones t o g i v e b i l l s of h e a l t h , a l s o r e s e n t i n g the thought of a foreign inspection of t h e i r s h i p s . defeated, had  2 0  This proposal was  easily  l a r g e l y as a r e s u l t of the i m p l i c a t i o n s i t would have  f o r each country's p r e s t i g e and n a t i o n a l s o v e r e i g n t y .  compromise was the c o u n t r y  reached, however, whereby a consular o f f i c i a l of  of d e s t i n a t i o n c o u l d endorse the b i l l  and be p r e s e n t at the i n s p e c t i o n of a s h i p , official  A  of the country  of departure  of h e a l t h  but the s a n i t a r y  would a c t u a l l y issue the  c e r t i f i c a t e and conduct the i n v e s t i g a t i o n . A s i g n i f i c a n t proposal was  f o r the establishment  that emerged from t h i s conference of an i n t e r n a t i o n a l organization to  exchange epidemiological information. the  previous  conference's  proposal  organization to study epidemics, was and emerged only i n 1907, An reaching  This suggestion for  a  as  with  scientific  slow i n coming to f r u i t i o n  twenty-five years  later.  important s c i e n t i f i c d i s c o v e r y t h a t was consequences on the debate between the  t o have f a r contagionists  37 and  the a n t i - c o n t a g i o n i s t s or s a n i t a t i o n i s t s was also  at t h i s conference. The  The y e l l o w f e v e r v i b r o was announced.  p r o p o s i t i o n that an insect, i n t h i s case a mosquito,  be the c a r r i e r of a disease, had  revealed  could  gave credence t o both theories and  the e f f e c t of suggesting that both should also be followed  to some degree.  The discovery of the i n s e c t vector also formed  the b a s i s f o r t h e l a t e r s c i e n t i f i c u n r a v e l l i n g o f t h e typhus and plague vibros, as they too were t r a n s f e r r e d from person to person through an intermediatary  agent.  This conference was unique i n other ways besides being the o n l y one t o be h e l d i n t h e Western Hemisphere.  I t marked the  f i r s t appearance o f the U n i t e d S t a t e s i n t h i s forum, and was the  first  twenty-six Europe.  truly  international sanitary  participants,  many from  conference,  beyond t h e b o r d e r s o f  Included were seven L a t i n American countries and even  Japan.  The breadth of p a r t i c i p a t i o n demonstrates how great the  spread o f e p i d e m i c d i s e a s e s  was a t t h i s time, r e a c h i n g  into the previously uncontaminated "new world". how  having  international  regulation  and a c t i o n  even  I t also shows  to control  this  s i t u a t i o n was needed and was becoming more a c c e p t a b l e , principle,  in  i f not yet i n action, t o a l l states.  THE SIXTH INTERNATIONAL SANITARY CONFERENCE: ROME, 1885 The  S i x t h International Sanitary  Conference was prompted  by the reappearance of cholera i n Egypt i n 1883. Italy  the o b j e c t i v e  of t h i s conference  agreement on standardized  was  I n i t i a t e d by t o secure an  requirements f o r quarantine,  which  38 were s t i l l q u i t e a r c h i a c d e s p i t e p r e v i o u s same i s s u e . reference  T h i s was t o be a p r a c t i c a l c o n f e r e n c e , w i t h o u t  to s c i e n t i f i c  transmission  c o n v e n t i o n s on the  of cholera.  debate o r t h e causes  and mode of  The major issue of the conference was  the r e g u l a t i o n of quarantine along the Suez Canal,  and despite  good i n t e n t i o n s , t h e o l d arguments o f t h e s a n i t a t i o n i s t s and the contagionists broke out once again. At t h i s time there was s t i l l great s c i e n t i f i c debate over the  causes o f t h e spread o f c h o l e r a .  means  of transmission  Although the c o r r e c t  was i d e n t i f i e d  as b e i n g  through  contaminated d r i n k i n g water as e a r l y as 1840 by John Snow and in  1854 by F i l i p p o Pacinni working independently, t h i s f a c t was  not t o be r e c o g n i z e d  f o r another h a l f century.  views o f Max von P e t t e n k o f e r , v i b r o was t r a n s m i t t e d  Instead the  who b e l i e v e d t h a t t h e c h o l e r a  through an i n t e r m e d i a r y  water, s o i l o r a i r , h e l d sway.  agent such as  The p e r s o n n o r m a l l y c r e d i t e d  with discovering the cholera vibro, Robert Koch, announced the discovery method water.  of t h i s  bacillus  of transmission 2 1  This  i n 1884, and proposed t h a t i t s  was through contaminated  was not w e l l  recieved  refuted the idea of a s p e c i f i c contagion, to  lose  by a d m i t t i n g  that  by t h e B r i t i s h ,  22  who  as they had the most  the disease  i n d i r e c t l y through human i n t e r c o u r s e .  drinking  was s p r e a d  even  The i n t e n s i t y of t h i s  s c i e n t i f i c debate was to prevent the conclusion of a successful sanitary code f o r another ten years. In t h e d i s c u s s i o n s  a t t h i s conference,  Great  Britain,  39 supported by the United States and Denmark, wanted the o l d method of q u a r a n t i n e their  objections,  the  to replace  w i t h m e d i c a l i n s p e c t i o n . Over  conference  recommended  the  re-  i n t r o d u c t i o n of a t w e n t y - f o u r hour p e r i o d of o b s e r v a t i o n f o r a l l h e a l t h y s h i p s p a s s i n g through the Suez Canal, and a t h r e e to s i x day quarantine f o r healthy persons Italy  and  Austria-Hungary,  from i n f e c t e d ships.  f e e l i n g at the g r e a t e s t r i s k of  i n f e c t i o n , were the strongest supporters of t h i s re-imposition. B r i t a i n and i t s colony, India, were represented by strong a n t i - c o n t a g i o n i s t s who,  throughout the conference, sought t o  have a l l r e s t r i c t i o n s on the passage of t h e i r s h i p s removed. T h i s l e d the o t h e r d e l e g a t e s t o accuse them of p l a c i n g t h e i r t r a d i n g i n t e r e s t s above the common concern of i n t e r n a t i o n a l health: "The Gladstonian government," said the German delegate, " [ i s ] b r u t a l l y s e t t i n g a s i d e the most elementary international  saftey."  2 3  Britain  staunchly  regard f o r  defended i t s  actions by c i t i n g the f a c t that cholera had never been d i r e c t l y imported  i n t o Europe by a v e s s e l r e a c h i n g the  from the Suez Canel. that  c h o l e r a was  preconcived that  Conference  B r i t a i n f u r t h e r a s s e r t e d t h a t the i d e a  imported  from  I n d i a was  notion, unsupported by evidence,  i t s delegates  had  agreed  to t h i s  some twenty years e a r l i e r .  n o t h i n g but despite the  of the  c h o l e r a was  Suez Canal.  Now  a  fact  " f a c t " a t the T h i r d  In the i n t e r v a l , B r i t i s h  t r a d e i n t e r e s t s had grown s u b s t a n t i a l l y , due opening  Mediterranean  Britain  i n p a r t t o the  maintained  that  t r a n s m i t t e d by the p i l g r i m a g e t o the M i d d l e East  40 and  then t o the r e s t  worthlessness  of  of Europe.  quarantine,  As  Britain  f u r t h e r p r o o f of the cited  the  fact  that  despite i t s close connections and trade with India they had not had an epidemic outbreak of cholera f o r close to twenty years. While the B r i t i s h r e f e r r e d t o the lessons they had learned through India  t h e i r experiences c o n t o l l i n g p e s t i l e n t diseases i n  as  being  the  reason  why  they  so  strongly  oppossed  quarantine, the damaging e f f e c t s these measures had upon t h e i r t r a d e must a l s o be viewed as a major f a c t o r .  Four out of every  f i v e s h i p s t r a n s v e r s i n g the Suez Canal were B r i t i s h , most of them o r i g i n a t i n g i n India.  As the B r i t i s h ambassador noted i n  a l e t t e r to the President of t h i s conference, the three to s i x day p e r i o d of q u a r a n t i n e t h a t was suggested would reduce the t i m e saved by u t i l i z i n g the Suez Canal t o two days, and  add  f u r t h e r t o the c o s t s a s s o c i a t e d w i t h the c a n a l , which were a l r e a d y l i t t l e l e s s than the a d d i t i o n a l c o s t s of r o u n d i n g the Cape i t s e l f . convention  As such, the B r i t i s h refused to sign the f i n a l  2 4  and the s i x t h c o n f e r e n c e was  adjourned  without  results. SEVENTH INTERNATIONAL SANITARY CONFERENCE: VENICE, The  Seventh  p r o v i d e the  International  first  limited  l i m i t e d r e g u l a t o r y code was from  the Mecca pilgrimage.  conference  and  participation.  had  1892  S a n i t a r y Conference  success  f o r these  was  to  endevours.  A  imposed on s h i p s t r a v e l i n g home Austria-Hungary had proposed  made s p e c i a l  efforts  t o secure  this  British  Since the l a s t conference, seven years e a r l i e r ,  41 B r i t a i n had was  not  not changed i t s p o s i t i o n regarding  anxious  to  resume i n t e r n a t i o n a l d i s c u s s i o n s  s u b j e c t where i t was promised  to  c o n s i s t e n t l y outvoted.  "endevour t o  conference everything interests". p r o t o c o l with  exclude  from  and on  a  Austria-Hungary  discussions  at  the  that might seem unacceptable to English  Austria-Hungary  2 5  quarantine  had  r e c e n t l y concluded a  B r i t a i n whereby B r i t i s h ships could pass f r e e l y  through the Suez Canal i f bound d i r e c t l y f o r a port w i t h i n the United  Kingdom.  At  the  opening  of  this  conference  they  suggested t h a t o t h e r c o u n t r i e s agree to a s i m i l a r p r o t o c o l . The B r i t i s h had proposed t h i s same idea at the l a s t conference i n Rome and now  added the promise t h a t s a n i t a r y guards would  board the v e s s e l f o r i t s voyage through the Suez to ensure that the ship's passengers and goods d i d not come i n t o contact the shore or other ships.  This proposal was  the o t h e r c o u n t r i e s ' d e l e g a t e s who  with  q u i c k l y vetoed by  p o i n t e d out t h a t t h e r e  was  no method of e n s u r i n g a s h i p c o u l d t r a n s v e r s e the Suez Canal without meeting objectionable weather f o r c i n g i t to land.  The  German d e l e g a t i o n s a r c a s t i c a l l y commented on the " s u p r i s i n g coincidence  between England's commercial i n t e r e s t s and i t s  s c i e n t i f i c convictions." ^ 2  A l i m i t e d agreement was Mecca Pilgrimage. unacceptable quarantine  reached, however, concerning  the  A l l ships returning northwards with f o u l or  bills  of  health  period of f i f t e e n days.  had  to  undergo  a  minimum  This i n s t i t u t e d a system of  p r o t e c t i o n f o r Europe against the importation  of cholera from  42 the pilgrimage, a measure that was to be r e i n s t i t u t e d from time to  time even i n t o the twentieth  century.  This convention  was  r e l a t i v e l y easy t o secure as i t was l i m i t e d t o p i l g r i m s h i p s and  thus d i d not encroach upon B r i t i s h commercial m a r i t i m e  i n t e r e s t s i n the s l i g h t e s t . It  had t a k e n  forty-one  years  to achieve  i n t e r n a t i o n a l agreement t o r e s t r a i n t h e spread diseases.  a  limited  o f epidemic  Progress was now t o quicken i n t h i s area w i t h the  s c i e n t i f i c d i s c o v e r y o f many o f t h e v i b r o s o f t h e p e s t i l e n t diseases.  The announcement  of the r o l e  mosquitoes i n t h e t r a n s m i s s i o n o f y e l l o w conference  fever at the f i f t h  had been f o l l o w e d by t h e d i s c o v e r y o f t h e c h o l e r a  v i b r o i n 1884. views  of the i n s e c t  Although t h i s discovery i n i t i a l l y supported the  of the c o n t a g i o n i s t s ,  i t gave f u t u r e c o n f e r e n c e s  a  s c i e n t i f i c base from which these m a t t e r s c o u l d be d i s c u s s e d . Consent was f a r from unanimous as t o t h e cause and means o f t r a n s m i s s i o n of the cholera v i b r o . disease,  Was c h o l e r a a c o n t a g i o u s  spread through human contact and f o u l d r i n k i n g water,  or were i n d i v i d u a l s p r e d i s p o s e d some m y s t e r i o u s  element,  t o t h e d i s e a s e by v i r t u e o f  as t h e B r i t i s h  question was soon to be answered by medical  believed?  This  science.  EIGHTH INTERNATIONAL SANITARY CONFERENCE: DRESDEN, 1893 The E i g h t h I n t e r n a t i o n a l S a n i t a r y Conference was again i n i t i a t e d by Austria-Hungary i n the hopes of reaching agreement on a s e t of c o d i f i e d quarantine the  regulations f o r Venice  same way t h a t t h e seventh conference  i n much  had e s t a b l i s h e d  43 r e g u l a t i o n s r e g a r d i n g t h e Suez Canal.  Austria-Hungary  was  g r e a t l y concerned with the serious impact quarantine measures, imposed the year p r e v i o u s l y as a response t o the f o r t h cholera epidemic,  had upon both i n t e r n a t i o n a l t r a v e l l e r s and commerce.  These r e s t r i c t i o n s were not " j u s t i f i e d by the requirements of a sanitary s e r v i c e based on the r e s u l t s won by modern s c i e n c e " .  27  Opinions regarding the u t i l i t y of quarantine were beginning t o change i n t h e f a c e o f modern developments i n both s c i e n c e and trade,  as Austria-Hungary's  O r i g i n a l l y Austria-Hungary  change i n opinions  demonstrates.  d i d not view quarantine measures as  an i s s u e i n need o f a t t e n t i o n ; t h e i r p o s i t i o n then  switched  w i t h i n a few y e a r s from one o f complete d i s i n t e r e s t t o b e i n g s t r o n g l y s u p p o r t i v e o f q u a r a n t i n e measures and, f u r t h e r , t o v i e w i n g these measures as b e i n g o b s t r u c t i v e t o t h e i r t r a d i n g interests. Not a l l n a t i o n s were ready t o abandon t h e i r t r u s t i n the v a l u e s o f q u a r a n t i n e , however. the Eighth Conference  When R u s s i a was t o propose a t  the removal of a l l sanitary regulations  on t h e Danube R i v e r , c i t i n g t h e damaging e f f e c t s t h i s had on international  traffic,  Romania. As a r e s u l t ,  this  i d e a was s t r o n g l y opposed by  a l l non-infected ships on the Danube had  t o endure a t h r e e day q u a r a n t i n e .  In o r d e r t o secure the  support o f o t h e r n a t i o n s f o r t h i s d e c i s i o n , point  out t h a t o n l y a minimal  t r a n s v e r s e d t h e Danube. growing  concern  Romaina had t o  amount o f Russia's s h i p p i n g  T h i s exchange i s evidence  t h a t many n a t i o n s were b e g i n n i n g  o f the to feel  44 towards the n e c e s s i t y of s e c u r i n g the removal of f i n a n c i a l l y damaging impidements to t r a d e .  28  Agreements were q u i c k l y reached on the f i n d i n g s of the s c i e n t i f i c committees of the Eighth Conference and i t closed a little  more t h a n a month a f t e r i t had  r e s u l t i n g convention  c o n v e n e d . In  the  t e n European n a t i o n s p r o m i s e d t o n o t i f y  each other quickly i f any outbreaks of cholera broke out within their territories, what was  and  also agreed to s p e c i f i c regulations of  p e r m i s s i b l e i n t h e i r quarantine  procedures.  The  only  goods that were to be subjected to r e s t r i c t i o n s were bed l i n e n s and  rags, which could e i t h e r be p r o h i b i t e d or d i s i n f e c t e d , but  were not quarantinable.  L e t t e r s and newspapers were to be free  of a l l r e s t r i c t i o n s and t o t r a v e l f r e e l y between c o u n t r i e s . Land q u a r a n t i n e  was  forbidden  d e t a i n e d i f they d i s p l a y e d now  become w i d e l y  transmitted conditions  by  played  t r a v e l l e r s c o u l d only  symptoms of c h o l e r a .  accepted  direct  and  that  cholera  human c o n t a c t ,  a great  was  but  As i t had  2 9  not  that  be  in  fact  unsanitary  role i n i t s transmission,  these  agreements were r e l a t i v e l y easy to secure. NINTH INTERNATIONAL SANITARY CONFERENCE: PARIS, The  French  initated  the  proceedings  1894 f o r the  Ninth  I n t e r n a t i o n a l Sanitary Conference to complete the process had begun with e a r l i e r conferences, Mecca  pilgrimages.  At  that  the s a n i t a r y c o n t r o l of the  i t s opening,  the  President  conference stressed the need to eliminate once and  of  the  f o r a l l the  major f a c t o r s i n the westward spread of cholera, which had been  45 determined e a r l i e r at the Seventh Conference i n Venice (1892). At t h i s t i m e s t a t e s had agreed on s t e p s t o p r e v e n t c h o l e r a from spreading to Egypt and the Mediterranean. was  This minor success  followed by the Eighth Conference i n Dresden  (1893) where  states agreed to a system of n o t i f i c a t i o n f o r the outbreaks of cholera and on the maximum precautions to be taken i n the event of a such an occurance.  30  The approach taken at t h i s Ninth Conference was  to d i f f e r  s i g n i f i c a n t l y from p r e v i o u s ones, as c o u n t r i e s were now concerned  w i t h the r e g u l a t i o n  less  of q u a r a n t i n e than w i t h the  r e d u c t i o n of the p o s s i b i l i t y of the spread of d i s e a s e at i t s source,  the  p i l g r i m a g e s themselves.  s a n i t a t i o n i s t s had school,  hence  this  l a r g e l y d e f e a t e d the r i v a l  the  attention  devoted  transmission of cholera at i t s source. up that included:  By  time  the  contagionist  to p r e v e n t i n g the  A convention was drawn  proposals f o r mandatory hygiene on p i l g r i m  ships, the establishment of a d d i t i o n a l f a c i l i t i e s on the route of the p i l g r i m a g e , and a "means t e s t " t h e i r p o i n t of d e p a r t u r e .  f o r the p i l g r i m s a t  T h i s l a s t i t e m was  the source of  strenuous objections from B r i t a i n and from Turkey whose assent would be necessary before the code could be put i n t o practise. Turkey  refused  to sign  r e l i g i o u s grounds;  this  c o n v e n t i o n on  cultural  i t reported that the pilgrimage was  and  one of  the f i v e b a s i c commandments of the Muslim r e l i g i o n and i t could not be  f o r b i d d e n by  any  international  c o n v e n t i o n or  code.  B r i t a i n ' s r e f u s a l was, i n p a r t , due t o the i m p o s s i b l e burdens  t h i s would have placed upon t h e i r Indian colony.  This p o s i t i o n  also must be seen as r e f l e c t i v e of t h e i r a s s e r t i o n that cholera was  not endemic t o I n d i a .  was  vital  refused  As the two c o u n t r i e s whose a s s e n t  f o r the N i n t h Convention t o be put i n t o to  development  sign,  this  conference  of i n t e r n a t i o n a l  added  sanitary  practise  little  to  regulations.  the  It is  s i g n i f i c a n t , though, t h a t i t was the t h i r d such c o n f e r e n c e i n the  short space of two years, demonstrating the importance and  urgency t h a t s t a t e s were b e g i n n i n g t o p l a c e on i n t e r n a t i o n a l action to control  the spread o f e p i d e m i c d i s e a s e s such as  cholera. TENTH INTERNATIONAL SANITARY CONFERENCE: VENICE, 1897 T h i s Conference d i f f e r e d major r e s p e c t .  from p a s t c o n f e r e n c e s i n one  While the o t h e r s had been convened  s p e c i f i c a l l y with cholera,  to deal  ( w i t h the e x c e p t i o n of the  fifth  t h a t was p r i m a r i l y concerned w i t h y e l l o w f e v e r ) , the p r i m a r y purpose of the Tenth was  t o d i s c u s s methods t o c u r t a i l  epidemic of plague that was  then spreading throughout  the  Europe.  Austria-Hungary had proposed t h i s meeting out of fear that i t s pilgrims  would  return  with  this  disease.  Many  countrie  had a l r e a d y f o r b i d d e n t h e i r c i t i z e n s t o a t t e n d the  pilgrimage and others such as Austria-Hungary adopted measures to deal with t h i s looming health The  first  European  special  crisis.  o r d e r of b u s i n e s s f o r t h i s c o n f e r e n c e was  secure the r a t i f i c a t i o n  of the 1894  to  c o n v e n t i o n on c h o l e r a .  This e f f o r t met with l i t t l e success except f o r the addition of  47 Britain  as  a  signatory.  A  new  convention  however, and signed by eighteen countries. external and  was  drawn  up,  I t d e a l t with both  i n t e r n a l European measures to c o n t r o l the plague,  the d i s i n f e c t i o n of ships and goods, and the s u r v e i l l a n c e that was  t o be  performed by  Sanitary Councils.  the  Egyptian  and  Constantinoplian  A p r o v i s i o n t h a t h e a l t h y passengers and  ships were to be given free passage regardless of the state of the b i l l s of h e a l t h was  adopted, d e m o n s t r a t i n g the advances  t h a t had been made i n d e f e a t i n g the p r i n c i p l e of  quarantine.  Obligatory  telegraphic notification  of the  plague was  a l s o unanimously accepted  by a l l c o u n t r i e s , even  those t h a t d i d not S t a t e s and Denmark.  s i g n the  convention,  first  cases  namely the  countries  United  N a t i o n - s t a t e s were b e g i n n i n g t o r e a l i z e  the importance of e p i d e m i o l o g i c a l i n f o r m a t i o n b e i n g between  of  as  effective  tools  in  relayed  controlling  the  outbreak and spread of p e s t i l e n t diseases. Despite  the  promise  of  immediately t h i s convention, for  shipping  solutions.  i n t e r e s t s , as  a l l s i g n a t o r i e s to i t was  implement  not to provide much r e l i e f  i t was  To remedy t h i s s i t u a t i o n ,  really  a patchwork  the suggestion  was  of  made  t h a t a t e c h n i c a l commission be e s t a b l i s h e d t o harmonize and c o d i f y the  four previous  conventions,  although t h i s  practical  s o l u t i o n would not be acted upon f o r s i x years. ELEVENTH INTERNATIONAL SANITARY CONFERENCE: PARIS, The factors.  convening of t h i s c o n f e r e n c e was In  the  first  place,  i f only  1903  a r e s u l t of many  for  administrative  48 purposes,  t h e r e was  accomplishments document.  an o b v i o u s  need t o c o n s o l i d a t e t h e  of the l a s t four conferences i n t o one coherent  Second, a congress of shipping i n t e r e s t s meeting at  Vienna i n 1902 had s t r o n g l y recommended t o t h e i r r e s p e c t i v e governments t h a t another s a n i t a r y c o n f e r e n c e be convened f o r the same p u r p o s e . 3 1  n a t i o n a l revenue them was  Trade was by now  f o r a l l European  an i m p o r t a n t source of  states.  Competition amongst  f i e r c e as they sought t o s e c u r e as much p r o f i t from  t h e i r overseas colonies as possible.  As l i b e r a l i s m  r u l e d the  p o l i t i c a l discourse of the day, known impediments to trade were being abandoned as quickly as possible. This conference was held i n Paris during the f a l l of at the i n v i t a t i o n of I t a l y . i n the b e l i e f that new pestilent  This conference had been convened  s c i e n f i t i c knowledge of the e t i o l o g y of  diseases c a l l e d  international  1903  for a  sanitary codes.  the l a s t conference i n 1897,  32  revision  of the  existing  I t had been determined  since  which had d e a l t almost e x c l u s i v e l y  w i t h the plague, t h a t r a t s p l a y e d a fundamental epidemiology of t h i s disease.  I t had also by now  r o l e i n the become known  through s c i e n t i f i c d i s c o v e r i e s and m e d i c a l advances t h a t the main i t e m s t o be e l i m i n a t e d or n e u t r a l i z e d i n c o n t r o l i n g the spread of p e s t i l e n t d i s e a s e s such as c h o l e r a , the plague, and yellow  fever,  were u n s a n i t a r y l i v i n g  i n s e c t s such as f l e a s and  mosquitos . 33  regarded p r i m a r i l y as a North American considered.  conditions,  rats  Yellow fever, i s s u e , was  and still  not t o be  T h i s conference, as w i t h the p r e v i o u s ones,  was  49 d e s i g n e d t o p r o t e c t Europe from t h e e x o t i c d i s e a s e s o f other lands  with  which  i t came i n t o c o n t a c t  through t r a d e . The  countries of the Americas were thus t a c k l i n g health issues by themselves. Two American Sanitary Conferences had already l e d to the c r e a t i o n of the Pan American Sanitary Bureau i n 1902. The  Eleventh  Conference had i n f a c t  o b j e c t i v e of u n i t i n g the four previous  succeeded i n i t s  c o n v e n t i o n s i n t o one  i n t e r n a t i o n a l sanitary code. I t was signed by twenty countries, and by 1907 sixteen of them had r a t i f i e d the convention. single  code r e p l a c e d  This  t h e near anarchy t h a t had p r e v i o u s l y  e x i s t e d with various conventions regarding the i m p o s i t i o n of quarantine.  The p e r i o d o f a l l o w a b l e  quarantine  was f u r t h e r  reduced from f i f t e e n days t o a maximum of f i v e . In p r a c t i s e i t was becoming i n c r e a s i n g l y popular system o f m e d i c a l i n s p e c t i o n . contained  two o b l i g a t o r y  to replace quarantine  Moreover, t h e new  principles.  necessity of a state informing  with a  convention  The f i r s t  was t h e  a l l other s i g n a t o r i e s of the  appearance o f an e p i d e m i c d i s e a s e w i t h i n t e r r i t o r y under i t s jurisdiction.  The second was that states, upon being  of such a s i t u a t i o n , afflicted  country  convention.  34  would not impose measures a g a i n s t t h e  i n excess o f what was p r e s c r i b e d by the  These p r i n c i p l e s were based on t h e l e s s o n s  l e a r n e d over t h e p a s t h a l f century control. disease,  While  notified  i t was important  of i n t e r n a t i o n a l disease t o c o n t r o l t h e spread of  i t was now agreed that measures could not unecessarily  i n t e r f e r e with  trade.  These two p r i n c i p l e s formed the basis  50 of the i n t e r n a t i o n a l health regulatory regime and remain  today  as e s s e n t i a l components. CONCLUSIONS - THE EARLY CONFERENCES Although accomplished steady  i t seems little,  progress  regime.  as t h o u g h  the e a r l y  conferences  they d i d i n f a c t c o n t r i b u t e slow y e t  towards t h e development o f today's h e a l t h  By t h e i r v e r y e x i s t e n c e t h e e a r l y c o n f e r e n c e s l e d  c o u n t r i e s t o a c c e p t i n t e r n a t i o n a l d i s c u s s i o n and a c t i o n on controversial  questions that  involved domestic  medical  p r a c t i s e s and trade questions, which p r e v i o u s l y would have been regarded as i s s u e s o f n a t i o n a l j u r s i d i c t i o n only. brought  arbitrary  scrutiny  of p u b l i c  They a l s o  and corrupt quarantine p r a c t i s e s under the debate.  In d e m o n s t r a t i n g  t h e damaging  e f f e c t s and the inadequacy of the contagionist theories, conferences  quickened  these  t h e s e a r c h f o r more r a t i o n a l and  s c i e n t i f i c premises t o e x p l a i n t h e spread and t h e n e c e s s a r y treatment to  f o r these p e s t i l e n t d i s e a s e s .  the E l e v e t h conference  35  The French delegate  (who had attended a l l s i n c e 1871,  with the exception of the F i f t h ) pointed out, "that although i t appears t h a t t h e f i r s t s i x c o n f e r e n c e s a c c o m p l i s h e d  little,  with no conventions r e s u l t i n g , they had i n f a c t , contributed to the d i s a p p e a r a n c e measures". After sanitary  o f e x c e s s i v e , absurd  and even  barbarous  36  fifty-three  years  an  acceptable  and  inclusive  code was d u l y s i g n e d and r a t i f i e d by a s u f f i c i e n t  number of states. An i n t e r n a t i o n a l health regulatory regime had  51 been c r e a t e d . remain  I t c o n t a i n e d two  i n the h e a l t h regime  d i l u t e d from.  The f i r s t was  diseases,  the second  and  essential  today,  principles  that  a l t h o u g h i n a somewhat  to contain the spread of epidemic  wass t o ensure the f i r s t  without  imposing unnecessary b a r r i e r s t o the f r e e f l o w of goods and commerce. There are a l s o two reasons why came to pass.  t h i s event  finally  The f i r s t was undoubtably the mounting pressure  that growing trade had placed upon nations to e l i m i n a t e or, at the minimum, to reduce and standardize the e x i s t i n g quarantine regulations that had proved to be such great impediments to the free flow of trade.  Second, advances had been made i n medical  knowledge and science regarding the sources of these p e s t i l i e n t d i s e a s e s which a l l o w e d s t a t e s t o r e a c h agreement on the most e f f e c t i v e methods of c o n t r o l l i n g the spread of disease. c l e a r that without these two developments,  It i s  agreement would not  have been p o s s i b l e i n t h i s area of i n t e r n a t i o n a l c o l l a b o r a t i o n .  52 ENDNOTES - CHAPTER TWO 1.  N e v i l l e Goodman, I n t e r n a t i o n a l H e a l t h Organizations and t h e i r Work, (London: C h u r c h i l l and Livingstone, 1971), p. 34-35.  2.  Ibid , p. 38.  3.  Norman Howard-Jones, "The S c i e n t i f i c Background o f the I n t e r n a t i a l S a n i t a r y C o n f e r e n c e s 1851-1938" i n C h r o n i c l e o f t h e World H e a l t h O r g a n i z a t i o n , Vol, 28., p. 161.  4.  The F i r s t Ten Years of the World Health Organizat i o n (Geneva: World Health Organization, 1958), p. 4.  5.  Goodman, p. 43.  6.  H. S. Gear and R. Duetchman, " D i s e a s e C o n t r o l and I n t e r n a t i o n a l Travel: A Review of I n t e r n a t i o n a l Sanitary R e g u l a t i o n s " , i n C h r o n i c l e of the World Health Organi z a t i o n , V o l , 10-11., p. 277.  7.  Gear and Deutchman. p. 277.  8.  I b i d . , p. 279.  9.  Howard-Jones, p.2 3 6.  10.  I b i d . , p. 235.  11.  Goodman, p. 55.  12.  Gear and Deutchman. p.236-237.  13.  Goodman, p. 58.  14.  Howard-Jones, p.245.  15.  Ibid.  16.  C i t e d i n Goodman, p. 59.  17.  C i t e d i n Goodman, p. 60.  18.  Howard-Jones, p. 370.  19.  C i t e d i n Howard-Jones, p. 370.  20.  Goodman, p. 61.  I t a l y was the exception.  53 21.  Howard-Jones, p. 376.  22.  I b i d . , p. 379.  23.  Cited i n Gooman, p. 64. Quotation i f from a speach by the French Delegate, quoting an a r t i c l e that appeared i n the Hungarian Press.  24.  Howard-Jones, p. 384.  25.  Cited i n Howard-Jones, p. 419.  26.  Cited i n Howard-Jones, p. 414.  27.  Cited i n Howard-Jones, p. 414. Included i n the introductory address made by the Austo-Hungairian delegate at the Eighth Conference.  28.  I b i d , p. 426.  29.  Ibid.  30.  Ibid, p. 455.  31.  Gear and Deutchman, p. 281.  32.  Howard-Jones, p. 464.  33.  I b i d , p. 465.  34.  Gear and Deutchman, p. 281.  35.  Ibid.  36.  Norman-Jones, p. 465.  54  CHAPTER THREE THE INSTITUTIONALIZATION OF THE HEALTH REGIME — THE ESTABLISHMENT OF INTERNATIONAL HEALTH ORGANIZATIONS  While the a r t of healing and t h e prevention of disease i s e s s e n t i a l l y world-wide, the t e c h n i c a l method of i t s a p p l i c a t i o n had been t o o o f t e n l i m i t e d by p o l i t i c o - g e o g r a p h i c a l boundaries. — M e l v i l l e D. Mackenzie  The  successful  adoption of an i n t e r n a t i o n a l sanitary code  i n 1903 a f t e r almost f i f t y y e a r s o f e f f o r t was t o foreshadow the  achievements of i n t e r n a t i o n a l p u b l i c  health  t h i s century.  This chapter w i l l be concerned with o u t l i n i n g the developments o r i g i n a t i n g i n t h e l a t t e r p a r t o f the n i n t e e n t h c e n t u r y t h a t m a n i f e s t e d themselves i n both t h e c r e a t i o n o f i n t e r n a t i o n a l health  organizations  and  comprehensive sanitary codes. the  of  several  These developments were l a r g e l y  r e s u l t of the changing s c i e n t i f i c philosophy f o r t r e a t i n g  epidemic diseases. by  i n the adoption  a policy  Quarantine was i n c r e a s i n g l y being  of disease  containment.  Instead  replaced  of erecting  b a r r i e r s t o p r e v e n t the spread o f d i s e a s e i t was d e c i d e d t o contain disease through epidemiological become  increasingly  transportation period  necessary  surveillance.  as new  This had  developments i n  reduced i n t e r n a t i o n a l t r a v e l time to below the  of incubation  f o r most  diseases.  As a r e s u l t ,  quarantine was no longer an e f f e c t i v e means of disease control.  55 I t was  r e a l i z e d that epidemic diseases  t h e i r source,  must be a r r e s t e d at  b e f o r e they c o u l d spread to o t h e r  This philosophy  of d i s e a s e  containment was  populations.  not t o be  fully  r e a l i z e d u n t i l the c r e a t i o n of the World Health Organization i n 1948.  The seeds of t h i s philosophy  i n the  a c t i o n s and  can be recognized,  deeds of the H e a l t h  however,  Organization  of  The  League o f N a t i o n s and the h e a l t h o r g a n i z a t i o n t h a t preceeded it. ORGANIZATION INTERNATIONAL D'HYGIENE PUBLIQUE 1907-1948 Acting upon a recommendation from the l a s t International Sanitary Conference i n 1903,  the f i r s t permanent i n t e r n a t i o n a l  health  O f f i c e I n t e r n a t i o n a l d'Hygiene  Publique  organization, (OIHP) was  the  founded i n 19 07 a t a c o n f e r e n c e i n Rome.  T h i s o r g a n i z a t i o n was t o be l o c a t e d i n P a r i s , w i t h the French also  taking  responsibility  r e f l e c t i n g t h e i r long-standing regulation.  Thirteen  1  c o n f e r e n c e and  f o r d r a f t i n g the c o n s t i t u t i o n , i n t e r e s t i n i n t e r n a t i o n a l health  countries  w i t h the e x c e p t i o n  S t a t e s , the d e l e g a t e s  attended  the  of B r a z i l and  were a l l European.  inaugural the  United  Notable f o r t h e i r  absence were the c o u n t r i e s o f Germany, A u s t r i a - H u n g a r y  and  Scandinavia. The purpose of the P a r i s O f f i c e , as the OIHP soon became known, was: participating  "to c o l l e c t s t a t e s the  and  b r i n g t o the knowledge of  f a c t s and  documents o f a  c h a r a c t e r which r e l a t e t o p u b l i c h e a l t h , regards  i n f e c t i o n s diseases,  notably  and  the  general  e s p e c i a l l y as  cholera,  plague  and  56  yellow  fever,  diseases."  well  as  measures taken t o  T h i s o f f i c e was  2  m e d i c a l and  as  these  a l s o to p r o v i d e a l i n k between  s c i e n t i f i c advances throughout the w o r l d and  keep the s a n i t a r y conventions up to date. however, the o r g a n i z a t i o n was  O f f i c e became a  information.  to  In actual p r a c t i s e ,  l a t e r t o take on a much g r e a t e r  r o l e i n i n t e r n a t i o n a l health regulation. Paris  combat  Most importantly  c l e a r i n g house f o r  the  epidemiological  Future sanitary conferences were to bestow upon  the o f f i c e the duties or r e c i e v i n g , organizing and t r a n s m i t t i n g t o members' p u b l i c h e a l t h o f f i c e s i n f o r m a t i o n r e g a r d i n g  the  s t a t u s of communicable d i s e a s e s such as the plague, c h o l e r a , yellow  f e v e r , typhus and smallpox, as w e l l as l i s t s of p o r t s  w i t h s a n i t a r y equipement f o r d e r a t i f i c a t i o n . information  enabled  Epidemiological compliance  of  traditionally  the  Report, the  office  which was  Sanitary  concerned  to  publish  useful  Codes,  about f a l l i n g  Gathering  as  the  Weekly  i n ensuring  nations  prey t o a  who  Gathering  the were  spreading  e p i d e m i c were a b l e t o a s c e r t a i n the t r u e s t a t u s and d i s e a s e posed t o them.  this  risk a  such i n f o r m a t i o n was  the  f i r s t step i n epidemiological disease containment. The  need  f o r an  international health  institution  had  f i n a l l y , a f t e r many years of discussion, become obvious, as had the  need  f o r a c e n t r a l u n i t to  s a n i t a r y conventions. organization enquiries,  i n t e r p r e t and  monitor  the  The c o o r d i n a t i o n of r e s e a r c h under one  avoided  saved time,  costly effort  d u p l i c a t i o n of and  money, and  scientific ensured  that  57 epidemiological members.  information  A l l states would now  knowledge and expert The  was  quickly transmitted  have the b e n e f i t of  assistance.  to a l l  scientific  3  P a r i s O f f i c e held i t s f i r s t meetings on the fourth i n  November, 1908,  with  n i n e c o u n t r i e s a t t e n d i n g . And  although  t h i s meeting produced l i t t l e p r a c t i c a l r e s u l t s , i t i s important t o observe t h a t  i t s orientation  from  the  a t t i t u d e of the  e a r l y s a n i t a r y c o n f e r e n c e s . Once a g a i n  the  e s s e n t i a l aim o f the e x c e r i s e was  differed l i t t l e  t o p r o t e c t Europe from the  importation of cholera and the plague. administrative d e t a i l s ,  t h i s conference d i d not a c t u a l l y begin  to discuss the t e c h n i c a l questions the s p r i n g of 1910.  Consumed l a r g e l y with  4  of p e s t i l e n t diseases  The h e a l t h agenda was  until  also s i g n i f i c a n t l y  broadened; where the focus had p r e v i o u s l y been on c o n t a g i o u s diseases  such  as  o c c a s i o n a l l y yellow become  a  topic  cholera,  the  plague,  smallpox,  fever, b i l o l o g i c a l standardization had  for  international action.  For  and now  example,  discussions took place on the necessary measures to ensure that the d i p t h e r i a a n t i t o x i n was  of equal potency i n every country.  Attempts were also made to coordinate health  statistical  standardization  of  contined  the  under  organizations The  purposes.  These  epidemiological auspicies  the reporting weeks f o r  of  e f f o r t s at  reporting future  were  to  the be  international  as w e l l .  P a r i s O f f i c e began p r e p a r a t i o n s  the Sanitary Convention of 1903  f o r the r e v i s i o n of  at i t s f i f t h session.  Members  58 agreed a t t h i s t i m e t h a t t h e s a n i t a r y p r e c a u t i o n s cholera  would be t h e main  item  d i s c u s s i o n on plague and y e l l o w The  on t h e agenda,  regarding with  some  fever a c t u a l l y taking place.  membership o f t h i s o r g a n i z a t i o n had expanded beyond the  confines of Europe; i t had r i s e n from nine to twenty-two states i n j u s t two s h o r t years. Australia,  Now d e l e g a t e s  from as f a r away as  A l g e r i a and even Canada attended,  and c o u n t r i e s  that had e a r l i e r expressed reservations about j o i n i n g the Paris O f f i c e agreed t o send delegates t o t h i s prepratory meeting.  A  notable exception was Great B r i t a i n and India, r e l y i n g not f o r the f i r s t t i m e i n the h i s t o r y o f t h e s a n i t a r y c o n f e r e n c e s their  own  judgement  regarding  health  safeguards  on  and the  imposition of quarantine. TWELFTH INTERNATIONAL SANITARY CONFERENCE: PARIS, 1912 The Twelfth International Sanitary Conference was attended by  forty-one  delegations  countries,  i n c l u d i n g China,  from L a t i n America.  Siam  and s i x t e e n  Although t h i s conference had  no formal connection with the OIHP other than prepatory  consul,  i t made use o f OIHP s t u d i e s and background m a t e r i a l , and the staff  of the Paris  O f f i c e were  p a r t i c i p a t e i n the d e l i b e r a t i o n s . As  repeatedly  to attend  and  determined  that  5  i t had by now been s c i e n t i f i c a l l y  h e a l t h y persons  c o u l d c a r r y the c h o l e r a v i b r o , t h e q u e s t i o n  r a i s e d a t t h i s c o n f e r e n c e was how l o n g c o u l d  otherwise healthy the  invited  person be reasonably  quarantined?  an  Despite  f a c t that i n t e r n a t i o n a l commercial i n t e r e s t s desired l e s s  59 rigorous  quarantine  pressure  on  periods,  the general  states to r e t a i n quarantine  these p e s t i l e n t diseases.  p u b l i c exerted  great  as p r o t e c t i o n against  In the end i t was  decided that " i n a  c o u n t r y where s a n i t a r y c o n d i t i o n s are good, the danger of the importation of cholera by germ c a r r i e r s i s minimal". I t was be  left  to  i n d i v i d u a l countries to decide  b a c t e r i o l o g i c a l t e s t i n g would be necessary.  to  whether f u r t h e r  6  The l a s t meeting of the OIHP had c o n f i r m e d the r o l e t h a t r a t s played  i n the t r a n s m i s s i o n  of  bubonic plague. I t  was  therefore strongly recommended at t h i s time that a l l merchant ships undergo systematic and p e r i o d i c d e r a t t i n g of t h e i r ships, to c o n t r o l the spread of t h i s disease. Y e l l o w f e v e r was meriting  a g a i n r a i s e d i n d i s c u s s s i o n as a d i s e a s e  international attention,  conferences  i t was  perceived  phenomena". T h e r e f o r e , delegate,  " i t was  conference." there  7  should  and  to  be  i n the  their  own  Sanitary  in  previous  "North  American  words o f t h e  British  T h i s comment sparked a debate as t o whether continue  the other  t h e i r own  a  as  i n a p p r o p r i a t e t o d i s c u s s i t at a European  t o be  a d i s t i n c t i o n between the  I n t e r n a t i o n a l Sanitary Conventions, one states,  but  seperate Bureau.  c o n s i s t i n g of European  of non-European states.  s a n i t i a r y conferences, health  Besides  the Americas had  organization, to  gather  Pan  American  epidemiological information w i t h i n the Americas i t had  already  Codes.  1901  a l s o formed  report  Sanitary  in  the  initiating  and  produced two  Created  two  I t s p r i m a r y f u n c t i o n was  to  s i m i l a r t o the OIHP's. I t f o r m u l a t e d s a n i t a r y agreements and regulations  with  requirements fever was the  the  o b j e c t i v e of  to a minimum.  reducing  quarantine  C o n t r o l l i n g the spread of yellow  8  a major concern of t h i s organization, but p r o t e c t i n g  United  States  and  other  American  c o u n t r i e s from  the  i m p o r t a t i o n of p e s t i l e n t d i s e a s e s from European immigrants became a l a t e r function of t h i s organization. The  Twelfth conference was  concluded,  a f t e r much debate,  w i t h a c o n v e n t i o n designed t o r e p l a c e the e x i s t i n g S a n i t a r y Code.  The  general trend towards reducing the a p p l i c a t i o n  damaging e f f e c t s of quarantine was also  made i n the c o n v e n t i o n  remain separate.  maintained. Provisions were  for controlling  y e l l o w f e v e r , a l t h o u g h the two  and  the spread  of  s a n i t a r y c o n f e r e n c e s were t o  The i n c l u s i o n of t h i s disease i n the European  regulations demonstrates the beginning of the gradual expansion of the sanitary regulations to include diseases outside the the immediate  concerns  implementation  Europe.  Unfortunately,  the  of t h i s code was d e l a y e d f o r e i g h t y e a r s as a  r e s u l t o f World War until  of  One;  i t d i d not a c t u a l l y come i n t o f o r c e  1920.  THE EFFECTS OF WORLD WAR ONE ON INTERNATIONAL HEALTH COLLABORATION World War  One,  l a s t i n g from  1914-1918, wreaked havoc not  only upon the p h y s i c a l and economic well-being of countries but a l s o upon the v e r y f a b r i c of European s o c i e t y i t s e l f . destruction  of  several  European  countries'  i n f r a s t r u c t u r e i n the aftermath of World War  One was  The  social  to have a  61  great  i n f l u e n c e on the development of i n t e r n a t i o n a l p u b l i c  health.  Issues of p u b l i c h e a l t h had  during  the war  years,  their  e f f o r t s on  struck with  neglected  with states instead concentrating a l l  f i g h t i n g the  deteriorating health  l a r g e l y been  and  war.  sanitary  As  a r e s u l t of  conditions,  the  Europe,  massive epidemics of influenza and  was  typhus, which  were p a r t i c u l a r l y severe i n the eastern sections of Poland i n Western R u s s i a . The s e r i o u s n e s s the O r g a n i z a t i o n  was  i t s President now  health  When the OIHP resumed meetings i n  suggested that as a r e s u l t of the war  affairs.  The  idea as  s c i e n t i f i c a l l y outdated.  of  erecting  developed  Unfortunately  public  of  the  health  OIHP.  services  new  epidemiological  Office,  as  declared to be  in a l l  a t t i t u d e was Staffed  against to  be  directed  at t h e i r source through  theories.  countries.  not  largely  veterans of e a r l i e r sanitary conferences, change and  barrier  A l l e f f o r t s were now  t h i s progressive  characteristic  a  w i t h q u a r a n t i n e was  at e l i m i n a t i n g these epidemic diseases  Paris  there  a need f o r a change i n o r i e n t a t i o n of i n t e r n a t i o n a l  contagious diseases  well  caused  I n t e r n a t i o n a l d'Hygiene P u b l i q u e t o r e f l e c t  upon i t s e s s e n t i a l purpose. 1919  of t h i s s i t u a t i o n  and  i t was  to  by  remain  seasoned  r e s i s t a n t to  Furthermore,  1 0  9  p r i m a r i l y a m o n i t o r i n g agency,  was  the not  empowered or equipped to provide the necessary a i d required to remedy the d r a s t i c s i t u a t i o n i n E a s t e r n Europe at t h i s time. This  was  organization  a  task  for  that had  the  International  been very successful  Red  Cross,  an  i n m o b i l i z i n g both  62  funds and volunteers to a i d the v i c t i m s of the war. After  t h e war, t h e League o f Red C r o s s e s b e l i e v e d i t  should continue disease  i t s o r i g i n a l goal to a i d humanity by combatting  throughout  the w o r l d .  1 1  This  coalition  of  organizations was a c t u a l l y the f i r s t to take steps towards the c r e a t i o n o f a postwar i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n . April  1919  representatives  of f i v e  national  organizations met to discuss the founding Red  the League o f  e f f o r t t o a n t i c i p a t e , d i m i n i s h and  r e l i e v e the misery produced by disease and c a l a m i t y . " doing,  i t would  international  of course  public  Cross  of an i n t e r n a t i o n a l  Cross s o c i e t y t h a t would cooperate w i t h  N a t i o n s i n "a s y s t e m a t i c  Red  In  cooperate  health  with  institution,  12  In so  the e x i s t i n g  t h e OIHP.  This  c o o p e r a t i o n was not t o be as easy t o secure as i t was i n i t i a l l y thought. DIFFICULTIES IN INTERNATIONALHEALTH COLLABORATION— INSTITUIONAL LOYALTY The  League of Nations,  designed s p e c i f i c a l l y t o safeguard  and promote t h e peace, a l s o c r e a t e d s e v e r a l t e c h n i c a l bodies. Included  i n i t s Covenant were three a r t i c l e s that deal with the  matter of i n t e r n a t i o n a l health. that the League of Nations was:  A r t i c l e Twenty-Three stated "to endeavour to take steps i n  matters of i n t e r n a t i o n a l concern f o r the prevention and control of disease."  A r t i c l e Twenty-Five f u r t h e r stated that: "members  of the League agree to encourage and promote the establishment and  cooperation  of duly authorized voluntary  N a t i o n a l Red  63 Cross a s s o c i a t i o n s , health,  h a v i n g as purposes t h e improvement o f  the prevention  of disease  s u f f e r i n g throughout t h e world." supportive  and t h e m i t i g a t i o n o f  While t h e League was f u l l y  o f t h e Red Cross i n i t i a l l y ,  especially  as the  Treaty of V e r s a i l l e s d i d not come i n t o force u n t i l January 1920 and current health problems needed immediate attention, i t also had  i t s own  organization.  aspirations  a s an i n t e r n a t i o n a l  health  Included i n the Covenant was A r t i c l e Twenty-Four  which states that "there s h a l l be placed under the d i r e c t i o n of the  League a l l i n t e r n a t i o n a l bureau e s t a b l i s h e d by  treaties  i f the p a r t i e s  t o such t r e a t i e s c o n s e n t . "  general 13  In  e f f e c t , t h i s p r o v i s i o n c a l l e d f o r t h e OIHP t o be subsumed by the a c t i v i t i e s of the new i n t e r n a t i o n a l health organization of the League.  T h i s was a p r o p o s a l t h a t was t o prove  impossible  to secure, as l a t e r events w i l l demonstrate. At f i r s t , t h e OIHP had g i v e n i t s a s s e n t t o a merger when the  League o f Red Crosses S o c i e t y had suggested i t i n 1919.  Yet  s i x months l a t e r t h i s organization had c l e a r l y changed i t s  mind:  i t r e j e c t e d the move i n d i c a t i n g that only the o r i g i n a l  signatories  o f t h e OIHP's Rome Convention c o u l d  alter i t s  assigned functions and purposes. While the P a r i s O f f i c e agreed to  have t e c h n i c a l  International preserve delegation  r e l a t i o n s with  Red Cross,  both t h e League and the  i t believed  i t must  i t s own independence and autonomy. had o b j e c t e d  also  act to  14  The French  t o t h e merger p r o p o s a l  at the l a s t  moment. They were g r e a t l y involved i n t h i s organization as both  64 the o r i g i n a l i n s t i g a t o r and as t h e home o f t h e o r g a n i z a t i o n . I t s demise might p o s s i b l y r e s u l t i n a l o s s o f p r e s t i g e and i n f l u e n c e f o r t h e French t h a t they c o u l d not r e c a p t u r e i n t h e League's organization.  They were supported i n t h i s view by the  U n i t e d S t a t e s which had f a i l e d t o r a t i f y t h e Covenant o f t h e League and, as a r e s u l t , r e f u s e d t o a l l o w t h e Arrangement de Rome t o be r e s c i n d e d  and t h e OIHP t o be absorbed i n t o the  League. Meanwhile the League of Nations had been unable t o proceed w i t h any o f i t s f u n c t i o n s .  A l l o f i t s e f f o r t s and e n e r g i e s  were consumed i n attempts t o gain the cooperation of the Paris Office. size  The League o f Red Cross S o c i e t i e s had grown, both i n  and b u d g e t ;  several  t o p - l e v e l medical  participated i n i t s activities.  At t h i s time,  scientists  i t was the only  e f f e c t i v e i n t e r n a t i o n a l p u b l i c health organization, not  only  a monthly  bulletin,  but a l s o ,  publishing  the bimonthly  I n t e r n a t i o n a l J o u r n a l o f P u b l i c Health, both o f which d e a l t e x c l u s i v e l y with epidemiological reports. The  d e a d l o c k between t h e League and. t h e OIHP  continued  unabated u n t i l June 1921 when the League proposed an ingenious s o l u t i o n , t h a t was t o have f a r r e a c h i n g consequences on the development o f f u t u r e i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n s .  A  " P r o v i s i o n a l Health Committee" was to be created, c o n s i s t i n g of fourteen i n d i v i d u a l s who were t o be selected by the Council of the  League on the strength of t h e i r t e c h n i c a l q u a l i f i c a t i o n s ,  and  n o t on t h e b a s i s  of t h e i r  nationality.  1 5  This  device  65 allowed  members o f t h e P a r i s O f f i c e t o p a r t i c i p a t e i n the  Health Organization fourteen  of the League's a c t i v i t i e s .  committee  members  were  i n fact  Twelve of the  members  o f the  Permanent Committee of the OIHP, but p a r t i c i p a t e d only i n t h e i r personal  capacities.  The League  o f Red C r o s s e s  and the  I n t e r n a t i o n a l Labour O r g a n i z a t i o n each a l s o sent a delegate. This  committee  was  to consult  circumstances required.  with  t h e OIHP  whenever  Except f o r routine communications and  the exchange of epidemiological information, r e a l c o l l a b o r a t i v e efforts  between these  two o r g a n i z a t i o n s  was t o r e m a i n  nonexistent. An  important precedent was established by the e f f o r t s of  the Health Organization of the League to surmount the obstacles regarding  cooperation  with  t h e OIHP. The i n v i t a t i o n t o  delegates  t o attend the League's health conference i n t h e i r own  personal  capacity  as h e a l t h  experts,  as opposed  t o being  representatives of t h e i r n a t i o n a l governments, established the p r i n c i p l e t h a t members o f i n t e r n a t i o n a l health organizations should be s e l e c t e d as i n d i v i d u a l s according t o t h e i r  scientific  and t e c h n i c a l merit, a p r i n c i p l e that remains i n t a c t i n the WHO today.  While t h e WHO i s a t t i m e s p o l i t i c a l l y charged due t o  i d e o l o g i c a l debate, t h e League l a r g e l y avoided t h i s f a t e as a r e s u l t o f t h i s compromise.  The League devoted i t s e l f almost  e x c l u s i v e l y to t e c h n i c a l i s s u e s . Soviet  Union  Committee  1 6  This s i t u a t i o n allowed the  t o p a r t i c i p a t e i n the I n t e r n a t i o n a l  o f t h e League,  which  was v i t a l l y  Health  necessary,  66 considering the state of i t s n a t i o n a l health, but was u n l i k e l y , considering the p o l i t i c a l tension between the Soviet Union and the r e s t of the members of the League. The  dispute between the Health Organization  and the OIHP was  not the f i r s t time that i n t e r n a t i o n a l p o l i t i c s  had intruded upon what was to  providing  of the League  a  supposedly an organization dedicated  mechanism  for  peaceful  multilateral  c o n s u l t a t i o n s between a l l n a t i o n s of the world, a s s i s t i n g i n the exchange of information i n t e c h n i c a l f i e l d s , course,  the  prevention  and  including, of  c o n t r o l of d i s e a s e .  At  1 7  the  i n i t i a l meetings where the H e a l t h O r g a n i z a t i o n of the League was  c r e a t e d , the French p h y s i c i a n s d e c l a r e d t h a t , w h i l e they  were  g r a t e f u l f o r the  humanitarian interpreted  endeavour, i n any  way  honour this as  of  cooperating  i n such  p a r t i c i p a t i o n could  suggesting  that  they  not  were  a be now  p r e p a r e d t o take up r e l a t i o n s of any k i n d w i t h the n a t i o n s they had  fought  a g a i n s t i n the Great War.  18  The p o l i t i c a l w o r l d  c o n t i n u a l l y i n t r u d e d upon attempts at t e c h n i c a l c o o p e r a t i o n . T h i s s i t u a t i o n , d e s p i t e the advances i n s c i e n t i f i c knowledge and cooperative s p i r i t , remains v i r t u a l l y unchanged today. Later attempts were made to r a t i o n a l i z e the structure of i n t e r n a t i o n a l p u b l i c health, e s p e c i a l l y when the League of Crosses began to c o l l a p s e i n 1923  Red  a f t e r the wartime enthusiasm  r e s p o n s i b l e f o r t h e i r i n i t i a l success began t o fade i n t o the background.  Efforts  oppossed by the OIHP.  at  rationalization  were c o n s t a n t l y  I t s strongest supporter was  the American  67 government, which d i d not want the P a r i s O f f i c e to be engulfed by  t h e League,  as t h e U n i t e d  States  would then l o s e i t s  foothold i n i n t e r n a t i o n a l health a f f a i r s . Other countries also opposed t h i s merger, however: an  action u n t i l  B r i t a i n refused t o condone such  American r e p r e s e n t a t i o n  League, and the French also objected,  was secure  i n the  f o r reasons of prestige.  A l l e f f o r t s a t r e c o n c i l i a t i o n ended i n f a i l u r e ; t h e OIHP and the Health Organization  of the League continued  to collaborate  only as much as necessary while remaining t o t a l l y independent. T h i s s i t u a t i o n was t o l a s t u n t i l t h e c o n c l u s i o n o f t h e Second World War and the formation  of a u n i f i e d i n t e r n a t i o n a l health  orgainzation i n i t s wake. The world  state of i n t e r n a t i o n a l p u b l i c health between the two  wars  was  organizations,  one o f f l u x  still  and change.  Older  health  advocates o f t h e a n c i e n t p r a c t i s e s i n  p u b l i c health, were slowly fading i n t o the background while the Health Organization of the League, embodying the newer b e l i e f s i n i n t e r n a t i o n a l hygiene and disease c o n t r o l , began slowly to gain i n both c r e d i b i l i t y and support. of t h e League g r e a t l y expanded  The Health  i t s original  Organization  functions. I t  created a Far Eastern Bureau located i n Singapore to report on the epidemiological s i t u a t i o n i n the Far East, e s p e c i a l l y with regards  t o t h e plague.  I t a l s o took over t h e p u b l i c a t i o n o f  the "Weekly Epidemiological Report" i n which f a c t s gathered by the OIHP were d i s t r i b u t e d to members of the League. in  the c o n t r o l of disease,  this  report  continued  Valuable t o be  68 p u b l i s h e d throughout the Second World War functions  of  these  two  organizations  when most  were  other  discontinued.  Advances were a l s o made i n e s t a b l i s h i n g minimum  acceptable  standards  and  in fields  such  as  nutrition,  housing  rural  hygiene towards which a l l nations were to s t r i v e . THE HEALTH ORGANIZATION OF THE LEAGUE ON NATIONS The League inaugurated a new cooperation with  form of i n t e r n a t i o n a l health  i t s M a l a r i a Commission.  I t enjoyed  great  success i n c o n t r o l l i n g malaria's insect vector through repeated spraying of i n s e c t i c i d e s . This body was form  to foreshadow the  of i n t e r n a t i o n a l t e c h n i c a l commissions t h a t would  c r e a t e d under the U n i t e d Nations. Commission was  be  The o b j e c t o f the M a l a r i a  not o n l y t o study and a d v i s e c o u n t r i e s on the  best means of c o n t r o l l i n g malaria w i t h i n t h e i r boundaries, to i n s t i t u t e  new  a new  but  approach i n i n t e r n a t i o n a l h e a l t h , which  went beyond the cordon s a n i t a i r e approach of q u a r a n t i n e  to  combatting diseases wherever they e x i s t e d by c o n t r o l l i n g t h e i r spread.  1 9  Work had a l s o s t a r t e d on the s t a n d a r d i z a t i o n and  u n i f i c a t i o n of v a r i o u s pharmacopias, which would e v e n t u a l l y have a great influence on the pharmaceutical developed  countries.  i n d u s t r i e s of the  A l l of these functions were to provide  the f o u n d a t i o n s f o r the t e c h n i c a l a s s i s t a n c e programs of the future World Health Organization. These achievements g r e a t l y d i f f e r e d  from the approach of  the OIHP, which remained f i r m l y rooted i n the epidemiological goals of the past —  to keep p e s t i l e n t diseases outside Europe  69 and  North America,  and t o l i m i t r e s t r i c t i o n s on i n t e r n a t i o n a l  trade and commerce.  There was l i t t l e concern with taking any  a c t i o n to a l l e v i a t e e i t h e r the s u f f e r i n g or the causes of these diseases  themselves.  The a n t i q u i t y o f t h e P a r i s O f f i c e ' s  m i s s i o n was p e r c i e v e d a t the time. I t d i d not enjoy the r e s p e c t of  the s c i e n t i f i c  community  which  t h e League's  O r g a n i z a t i o n came i n c r e a s i n g l y t o possess. then  considered  bureaucrats  t o be l a r g e l y  "a c l u b  Health  The OIHP was by  of e l d e r l y  health  ... t h a t had been r e l u c t a n t t o r e n o u n c e t h e  gastronomic and other d e l i g h t s of Paris".  For the two interwar  decades i t was viewed as t h e o n l y o b s t a c l e t o t h e r e a l i z a t i o n of  the i d e a l  organization.  o f a s i n g l e worldwide 2 0  This  goal  was  international health  finally  achieved  with the  formation of the World Health Organization i n 1948, which owed much o f i t s h e r i t a g e t o p r e c e d e n t s e s t a b l i s h e d by t h e H e a l t h Organization of the League. While  the Health  Organization  o f t h e League  i n c r e a s i n g l y p r o v i d i n g both a d v i c e and a i d f o r c o u n t r i e s  was to  deal with t h e i r i n t e r n a l health care problems, the P a r i s O f f i c e was s t i l l  concerned w i t h t h e s u p e r v i s i o n and r e g u l a t i o n o f  i n t e r n a t i o n a l quarantine  measures.  oversaw an agreement signed  F o r i n s t a n c e , i n 1924 i t  i n Brussels by fourteen countries  r e g a r d i n g arrangements f o r t h e t r e a t m e n t o f merchant seamen suffering  from v e n e r e a l  necessary  advance p r e p a r a t i o n s  Conferences, s t i l l  diseases.  The OIHP a l s o made the  f o r International Sanitary  l a r g e l y concerned w i t h t h e r e g u l a t i o n of  70 quarantine traffic,  i n o r d e r t o l e s s e n the impediments t o commercial  while p r o t e c t i n g the Western developed world from the  importation already  of exotic diseases.  well  established;  These guiding p r i n c i p l e s were  they now  had  t o be  applied  and  r e i n t e r p r e t e d f o r a changing world i n terms of transportation and mass t r a v e l .  International commerce demanded the extention  of the p r i n c i p l e s of the h e a l t h regime t o c o v e r new concern that had only r e c e n t l y a r i s e n with  modernization.  THIRTEENTH INTERNATIONAL SANITARY CONFERENCE: PARIS, The  Thirteenth  convened i n 1926  areas of  International Sanitary  1926  Conference  (the seventy-sixth year of such meetings), to  debate a g a i n the v i r t u e s of l a n d and sea quarantine. five  states  was  assembled  consider  whether  were necessary.  Technical  commissions studied three health problems: cholera,  influenza  modifications to the 1912  in  Paris  convention  to  Sixty-  and the c o n t r o l of r a t s i n preventing the plague. i t was  decided that quarantine was  of c o n t a i n i n g  the  spread  In each case  not the most e f f e c t i v e means  o f these d i s e a s e s .  States  expressed r e l u c t a n c e i n d e t a i n i n g o t h e r w i s e h e a l t h y carriers.  With  influenza was  s i m i l a r reasoning,  Instead of the quarantine  t h e i r cargo, i t was  plague.  the  Two  cholera  decided  f a r too prevalent to be the subject of  restrictions.  of r a t s was  i t was  again  that  quarantine  of suspected  ships and  determined that the d e s t r u c t i o n and control  best  prevention  f o r the  additional diseases  spread  were  of bubonic  added  to  the  i n t e r n a t i o n a l p u b l i c health agenda at t h i s time: typhus, which  71 had  struck Europe i n epidemic proportions  World War, and s m a l l p o x .  f o l l o w i n g the F i r s t  21  As demonstrated by these d e c i s i o n s , s t a t e s had begun t o move f i r m l y away from the o l d fashioned and b i l l s of health. were being ships.  concept of quarantine  In i t s place, i n t e r n a t i o n a l c e r t i f i c a t e s  issued t o c e r t i f y the d e r a t i f i c a t i o n and health of  Decisions  regarding  t h e h e a l t h o f s h i p s were t o be  a s s e s s e d on t h e b a s i s o f t h e i r a c t u a l c o n d i t i o n once r e a c h i n g t h e i r d e s t i n a t i o n , rather than at t h e i r point of departure, was the previous p r a c t i s e .  Furthermore, quarantine,  as  i f i t was  t o be imposed a t a l l , was not t o exceed t h e maximum l i m i t as decided by t h i s sanitary convention.  These measures acted to  22  reduce g r e a t l y t h e r e m a i n i n g h e a l t h - r e l a t e d b a r r i e r s t o t h e free  flow  of trade  and commerce.  The c o n v e n t i o n  was d u l y  signed by a l l members and remained i n force u n t i l 1952 when the World Health Assembly drafted a new version. At  this  conference  political  overtones  once  again  overshadowed the spectre of i n t e r n a t i o n a l c o l l a b o r a t i o n i n t h i s supposedly noncontentious area of i n t e r n a t i o n a l r e l a t i o n s . The U n i t e d S t a t e s made i t e x p r e s s l y c l e a r when s i g n i n g t h e f i n a l convention  t h a t t h i s a c t i n no way i m p l i e d i t s r e c o g n i t i o n of  another s i g n a t o r y . signatory,  with  T h i s move was aimed a t t h e USSR, a l s o a  whom t h e U n i t e d  States  was not t o enjoy  diplomatic r e l a t i o n s f o r another seven y e a r s . Egypt  also  expressed  23  i t s extreme d i s p l e a s u r e  a t the  c o n t i n u a n c e o f t h e S a n i t a r y Consul t h a t had been e s t a b l i s h e d  72 the century  previously t o oversee maritime quarantine  Suez Canal.  This organization, administered  f o r the  by f o r e i g n powers,  was an a f f r o n t t o E g y p t i a n s o v e r e i g n t y . Egypt's p u b l i c h e a l t h care system, i t s delegate task.  reported,  could e a s i l y perform  this  T h i s s i t u a t i o n was r e c t i f i e d t w e l v e years l a t e r a t the  Fourteenth  I n t e r n a t i o n a l Sanitary Conference i n 1938, where i t  was t h e s o l e item on t h e agenda. clause  A t t h i s same c o n v e n t i o n a  was i n s e r t e d i n t h e 192 6 c o n v e n t i o n  Permanent  Committee  which made the  of the P a r i s O f f i c e the "court of  a r b i t r a t i o n " f o r the i n t e r p r e t a t i o n of s a n i t a r y  conventions.  This development shows states' growing r e c o g n i t i o n on the need for  arbitration  regulations.  in interpreting  States were s t i l l  international  health  imposing excessive measures i n  v i o l a t i o n of i n t e r n a t i o n a l arrangements i f they f e l t i t was i n t h e i r n a t i o n a l i n t e r e s t t o have a d d i t i o n a l p r o t e c t i o n . countries adversely  a f f e c t e d by these actions wanted  And  recourse  to an i m p a r t i a l body f o r adjudication. T h i s was t o be one o f t h e l a s t I n t e r n a t i o n a l S a n i t a r y Conferences, cooperation sanitary  as i t was a mode o f i n t e r n a t i o n a l h e a l t h  that was r a p i d l y becoming outdated.  arrangements had a l r e a d y  epidemic diseases,  Comprehensive  been concluded  and o n l y p e r i o d i c u p d a t i n g  f o r most  was needed t o  respond t o new developments that a f f e c t e d t h e i r operation. As  a result  of i n c r e a s i n g a i r t r a v e l  i t soon became  obvious that the previous sanitary regulations would need t o be modified  to  administer  adequately  this  new  area  of  73 i n t e r n a t i o n a l concern. the  documents  the  I n t e r n a t i o n a l S a n i t a r y Convention f o r A e r i a l Navigation  came  the  c i r c u l a t e d and  in  Agreement had been r e l a t i v e l y easy t o s e c u r e f o r  p r i n c i p l e s of  longer  merely  not c a l l e d , 1935  into force.  were  This time a conference was  sanitary  contentious.  The  c o n t r o l and underlying  international sanitary regulations  r e g u l a t i o n were assumptions  had  the  been e s t a b l i s h e d  e a r l i e r conferences c r e a t i n g an i n t e r n a t i o n a l health regime.  of  at  regulatory  I t s norms and p r i n c i p l e s were designed to ensure the  maximum s e c u r i t y against  the  i n t e r n a t i o n a l spread of  w i t h a minimum i n t e r f e r e n c e w i t h w o r l d t r a f f i c . c o n v e n t i o n was,  i n f a c t , the  adapted to the conditions  The  maritime regulations  of a i r t r a v e l .  disease aerial of  1926  Previous conventions  had d e a l t only with the r e g u l a t i o n of maritime quarantines, i t had  no  as  e a r l i e r been e s t a b l i s h e d a t the F o u r t h I n t e r n a t i o n a l  Sanitary  Conference that land quarantine was  and useless  i n preventing  the spread of  both i m p r a c t i c a l  disease.  Eventually, as i n t e r n a t i o n a l t r a v e l became more extensive, the  norms o f  this sanitary  r e g i m e w o u l d be  updated  and  s i g n i f i c a n t l y changed. This process would not t r u l y begin u n t i l after  the  Second  developments regulations. occasion  World  would This  War,  however,  precipitate  would not  be  the  technological  revision first,  nor  of the  these changes would have t h i s e f f e c t upon the  regime. THE  a  when  EFFECTS OF THE SECOND WORLD WAR ON INTERNATIONAL HEALTH COLLABORATION  health last, health  74  With the e r u p t i o n of war i n Europe y e t again, the scope of i n t e r n a t i o n a l p u b l i c h e a l t h r e t u r n e d t o i t s former epidemiological r e p o r t i n g and The  Health  throughout  O r g a n i z a t i o n of the  war.  r o l e of  the p r o v i s i o n of emergency aid. the  League c o n t i n u e d  I t s r e p u t a t i o n was  to  greatly  exist  reduced,  however, as the s t a t u r e of the League of N a t i o n s d e c l i n e d .  2 4  Along with the remaining members of the OIHP, i t continued to p u b l i s h the Weekly Epidemiological Report  and provide as much  epidemic i n t e l l i g e n c e as possible, but t h i s became i n c r e a s i n g l y difficult  as the war  progressed.  New  developments,  pioneered  by the work of the H e a l t h O r g a n i z a t i o n of the League i n areas such as n u t r i t i o n and housing standards, and the f e a s i b i l i t y of health insurance schemes, were forced to be abandoned i n order t o d e a l w i t h the l a r g e r h e a l t h problems t h a t the war c r e a t e d . Although  these  foreshadow  the  development.  25  were t o be  l i m i t e d ventures,  next  of  stage  international  they public  were t o health  In i t s short duration, the Health Organization  of the League had managed to s h i f t the purpose of i n t e r n a t i o n a l health  cooperation  from  limiting  quarantine  measures  a r r e s t i n g the spread of disease from underdeveloped attacking these p e s t i l e n t diseases themselves,  and  nations, to  by improving the  strength of the developing world's health care services.  This  change was brought about l a r g e l y as a r e s u l t of the t e c h n i c a l nature  o f t h e H e a l t h O r g a n i z a t i o n o f t h e League's work.  T e c h n i c a l e l i t e s assesed s i t u a t i o n s on the b a s i s of m e d i c a l need,  r a t h e r than p o l i t i c a l  orientation.  For t h i s  reason  75  c e r t a i n a c t i v i t i e s of thes organization were h i g h l y successful. POST WAR HEALTH COLLABORATION - THE UNITED NATIONS RELIEF AND REHABILITATION ADMINISTRATION Immediate a c t i o n was needed to respond t o the health care emergencies World War Two created. quickly  to e s t a b l i s h  The A l l i e d countries moved  the United  Rehabilitation Administration  R e l i e f and  (UNRRA) i n 1943. They r e c a l l e d  the h e a l t h d i s a s t e r s t h a t f o l l o w e d One.  Nations  i n t h e wake o f World War  Smaller health agencies were formed i n i t a l l y , such as the  I n t e r - A l l i e d Post-War R e l i e f Committee i n 1941, but i t soon became c l e a r that a much l a r g e r organization  would be needed  to deal with the approximately f i f t y to seventy-five  million  people who would be medically d e s t i t u t e a f t e r the l i b e r a t i o n of Europe. H e a l t h care was o n l y a s m a l l p a r t o f UNRRA's d u t i e s , y e t it  was one o f i t s l e a s t c o n t r o v e r s i a l and most  activites.  I t was, at i t s time, the l a r g e s t intergovernmental  cooperative  e f f o r t i n the f i e l d o f h e a l t h . 2 6  o r g a n i z a t i o n was t o p r o v i d e Europe: shelter,  successful  relief  from  The aim o f t h i s  f o r the l i b e r a t e d p o p u l a t i o n  immediate  s u f f e r i n g ; food;  of  clothing;  and assistance i n the return of p r i s i o n e r s and e x i l e s  t o t h e i r homes.  A l s o r e q u i r e d , as a r e s u l t o f such a l a r g e  displacement of persons, were measures of a i d i n the prevention of p e s t i l e n t diseases. This  organization  also  i n s t i g a t e d epidemic  control  measures through the d i s t r i b u t i o n of medical personal,  supplies  76 and  sprayings  malaria  and  plague  and  of  DDT.  yellow the  tuberculosis,  This  was  to  fever vectors.  more  social  designed  to  organizations.  the  In 1946  gap its  continuance  avoiding  the  adminstration West had  of  a i d to  political  as  disease a l s o necessitated 1945  administration  and  nature a temporary s o l u t i o n , between  the  funds and  two  countries  disputes  world  health  duties were transfered  to the Interim Commission of the United Nations. the  such  information.  i t s very  bridge  cholera,  In a d d i t i o n t o t h e s e f u n c t i o n s , i n  r e p o r t i n g of epidemiological by  typhus,  diseases  UNRRA r e p l a c e d the P a r i s O f f i c e i n the  UNRRA was  the  Outbreaks of  epidemic  influenza and venereal  UNRRA's a t t e n t i o n .  eliminate  still  that  had  This  allowed  i n need,  while  a r i s e n over  the  of UNRRA s u p p l i e s . The A l l i e d c o u n t r i e s of the  declared  t h a t they were not p r e p a r e d t o  supplying t h i s organization a f t e r 1946, were r e c e i v i n g nothing  but  from the r e c i p i e n t nations.  continue  as they believed they  opposition and  h o s t i l i t y i n return  This, no doubt, r e f e r r e d to t h e i r  disappointment over the p o l i t i c a l o r i e n t a t i o n of the of Eastern Europe. This move was  countries  regarded by the USSR as  that East and West could not cooperate.  27  proof  This development  was  not t o s e t a p o s i t i v e note upon which to i n i t i a t e the U n i t e d Nations  as  the  first  global  peace  and  social  welfare  organization. ORIGINS OF THE WORLD HEALTH ORGANIZATION Although i n t e r n a t i o n a l p u b l i c health had been a prominent  77 aspect of the League of Nations, the need f o r t h i s s e r v i c e was abundantly  c l e a r i n the aftermath of the Second World War. This  t o p i c was i n i t i a l l y overlooked i n the discussions leading up to the  formation of the United Nations;  United Nations Conference  i t was not u n t i l the  on I n t e r n a t i o n a l Organizations at San  Francisco that the idea of i n c l u d i n g i n t e r n a t i o n a l health as a f i e l d of UN a c t i v i t i e s was raised.  Discussion on t h i s matter  was i n s t i g a t e d by the Chinese and B r a z i l i a n delegations.  Their  i n i t i a t i v e i n t h i s m a t t e r i s s i g n i f i c a n t as i t came from two developing countries, suggesting the future o r i e n t a t i o n of t h i s organization. As time progressed t h i s organization would to  increasingly  nations,  represent the i n t e r e s t s  whereas previous  come  of the developing  i n t e r n a t i o n a l health  institutions,  on t h e whole, were c r e a t e d by t h e developed n a t i o n s t o serve their  interests. A r t i c l e F i f t y - F i v e o f t h e C h a r t e r o f t h e U n i t e d Nations  recognized h e a l t h as an i n t e r n a t i o n a l f i e l d activities,  while  Article  f o r United Nations  Fifty-Seven provided  f o r the  establishment of a s p e c i a l i z e d health agency with wide powers. A t e c h n i c a l P r e p a r a t o r y Committee met i n 1946 t o d i s c u s s t h e form  this  o r g a n i z a t i o n should  take.  At t h i s  meeting the  c o n s t i t u t i o n of the organization was drafted and agreement was reached  regarding the fate of previous e x i s t i n g  health  bodies.  international  The H e a l t h O r g a n i z a t i o n o f t h e League's  f u n c t i o n s were t o be c o m p l e t e l y taken over by t h e new U n i t e d Nations health organization, and t h i s time  the s c i e n t i f i c a l l y  78 and  m e d i c a l l y outdated  absorbed without Yet the  of a s i n g l e ,  centralized  international  not to occur with complete ease. This time the  Pan American Sanitary Bureau objected to i t s proposed by the WHO.  was  a struggle.  formation  health body was  O r g a n i z a t i o n d'Hygiene P u b l i q u e  takeover  The c o u n t r i e s of L a t i n America s t r o n g l y opposed  t h i s measure. They wished to p r e s e r v e t h e i r a b i l i t y t o form a regional body, as they had been able to secure i n the p r o v i s i o n f o r r e g i o n a l c o l l e c t i v e defense under A r t i c l e Fifty-Two of the C h a r t e r of the U n i t e d Nations.  A compromise was  reached,  however, whereby the Pan American S a n i t a r y Bureau became a r e g i o n a l body w i t h i n the World H e a l t h O r g a n i z a t i o n . The PASB c o n t i n u e d t o perform WHO  remaining  i t s t r a d i t i o n a l f u n c t i o n s , but w i t h the  s u p e r i o r i n e s t a b l i s h i n g the g e n e r a l g o a l s and  objectives  f o r the  action  to create a highly decentralized i n t e r n a t i o n a l  was  organization.  The  end  result  of  this  organization. Representation g l o b a l i n scope. who  were  not  organization  i n t h i s o r g a n i z a t i o n was  designed  t o be  A l l nations were i n v i t e d to j o i n , even those members  of  the  UN.  a l l members were t o be  As  well,  equal.  within  the  There were  permanent functions assigned to any s p e c i f i c member,  no  although  i n p r a c t i s e those nations with the highest l e v e l of t e c h n i c a l e x p e r t i s e came t o y i e l d the most i n f l u e n c e .  In a manoeuvre  c a r r i e d over from the provisions of the Health Organization of the League, d e l e g a t e s  were t o be chosen a c c o r d i n g t o  their  79 technical merely  competence i n the f i e l d  to represent  international suggested  health  that  administrations responsible as  their care  country,  come  o f members,  the p r a c t i s e  from  Further,  2 8  the n a t i o n a l  The WHO  representation,  and t o t h i s end  o f communicating  by t h e i r very n a t u r e p o l i t i c a l  could not be t o t a l l y The  health  desired t e c h n i c a l ,  directly  n a t i o n a l health m i n i s t r i e s . Although interference from ministries,  i t was  as opposed t o t h e departments  f o r foreign a f f a i r s .  established  and were not  but t h e p r i n c i p l e s o f  in general.  delegations  opposed t o p o l i t i c a l ,  of health,  with  foreign  i n orientation,  eliminated.  fundamental  d i f f e r e n c e s between t h e World  Health  O r g a n i z a t i o n and i t s p r e c u r s o r s can b e s t be found w i t h i n the c o n s t i t u t i o n o f t h e World H e a l t h O r g a n i z a t i o n .  A r t i c l e One  s t a t e s t h a t : "the o b j e c t i v e o f t h i s o r g a n i z a t i o n s h a l l be t h e a t t a i n m e n t by a l l p e o p l e s o f t h e h i g h e s t p o s s i b l e l e v e l o f health".  Further,  i n Appendix E i g h t t o t h e c o n s t i t u t i o n ,  h e a l t h i s d e f i n e d as:  "a s t a t e o f complete p h y s i c a l , mental  and s o c i a l well-being and not merely the absence of disease or i n f i r m i t y . The  enjoyment of the highest a t t a i n a b l e standard of  h e a l t h i s one o f t h e fundamental r i g h t s o f every human being without  distinction  o f race,  economic or s o c i a l condition." idea  that  more was r e q u i r e d  religion,  political  belief,  The WHO was founded upon the from  an i n t e r n a t i o n a l h e a l t h  o r g a n i z a t i o n than an i n t e r n a t i o n a l system o f defence a g a i n s t common d i s e a s e s .  One o f i t s d e c l a r e d  functions  was t o  80  strengthen  the health services of member governments  programs of d i r e c t t e c h n i c a l a s s i s t a n c e .  through  This doctrine i s  s t a t e d i n t h e f i r s t Annual Report o f t h e D i r e c t o r General o f the WHO:  "the World Health Organiztion's fundamental objective  i s t o strengthen  the health services of member goverments." I t  reappears l a t e r i n h i s t h i r d report:  "WHO's t h i r d f u l l year of  a c t i v i t y was c h a r a c t e r i z e d by t h e g r a d u a l , but u n m i s t a k a b l e development of a world health consciousness  and by a broadening  of the general concept of the r i g h t t o health." In i t s f i r s t few years, t h e o r g a n i z a t i o n was t o c o n t i n u e with the o l d pattern of serving the i n t e r e s t s of the developed states,  a t t h e expense  of those  who most  needed  a s s i s t a n c e . The o r g a n i z a t i o n was t o be f u r t h e r d e l a y e d  their from  implementing i t s stated long-term goal of improving the health of  a l l citizens  by t h e e m o t i o n a l  appeal  of a  short-term  s o l u t i o n t o t h e problem o f c o n t a g i o u s d i s e a s e s by i n i a t i n g a s e l e c t e d program o f d i s e a s e occurrences,  eradication.  2 9  Despite  these  the WHO was an improvement over past i n t e r n a t i o n a l  health organizations.  The scope o f c o l l a b o r a t i o n broadened,  and a t r u e p r o g r e s s i o n i n t h e work o f t h e o r g a n i z a t i o n can be seen developing subject of  over the years.  This progression w i l l form the  d i s c u s s i o n f o r the next chapter.  81  ENDNOTES - CHAPTER THREE 1.  Norman Howard-Jones, "The S c i e n t i f i c Background o f t h e I n t e r n a t i o n a l Sanitary Conferences" i n Chronicle of the World H e a l t h O r g a n i z a t i o n , (Geneva: WHO, 1975) V o l 34, p. 468.  2.  A r t i c l e Four - Annex t o the Rome Convention - Statutes of the C o n s t i t u t i o n of the Organization d'Hygiene Publique.  3.  A r t i c l e Five - Annex t o the Rome Convention.  4.  Howard-Jones, "The S c i e n t i f i c Background I n t e r n a t i o n a l Sanitary Conferences", p. 468.  5.  I b i d . , p. 495.  6.  I b i d . , p. 497.  7.  I b i d . , p. 496.  8.  Norman Howard-Jones, The Pan American Health Organization: Origins and Evolution, (Geneva: WHO, 1981), p. 7.  9.  Norman Howard-Jones, "The S c i e n t i f i c Background o f t h e I n t e r n a t i o n a l Sanitary Conferences", p. 499.  10.  Norman Howard-Jones, "International P u b l i c Health Between the Two World Wars", (Geneva: WHO, 1978), p. 17.  11.  I b i d . , P. 1.  12.  I b i d . , P- 13.  13 .  I b i d . , P- 15.  14.  I b i d . , P- 16.  15.  I b i d . , P- 29.  16.  I b i d . , P- 7.  17.  I b i d . , P-  18.  Norman Howard-Jones. "The World H e a l t h O r g a n i z a t i o n i n H i s t o r i c a l Perspective", Perspectives i n B i o l o g y and Medicine, v o l . 24, 1981., p. 469.  19.  of the  11.  "Evolution of International Cooperation C h r o n i c l e V o l 12, #7-8, p. 267.  i n P u b l i c Health",  82  20.  Howard-Jones, " I n t e r n a t i o n a l P u b l i c H e a l t h Between the Two World Wars", p. 73.  21.  Howard-Jones, "The S c i e n t i f i c International Sanitary Conferences",  22.  N e v i l l e Goodman, I n t e r n a t i o n a l Health Organizations and T h e i r Work, ( B a l t i m o r e : The W i l l i a m s and W i l k i n s Co., 1971) p. 73-74.  23.  Howard-Jones, "The S c i e n t i f i c I n t e r n a t i o n a l Sanitary Conferences",  24.  As d e c i d e d a t t h e F o u r t h Conference i n Vienna, 1874.  25.  C. E. A l l e n , " W o r l d H e a l t h and W o r l d International Organizations 4, (1950), p. 30.  26.  Goodman, p. 134.  27.  I b i d , p. 138.  28.  Ibid, p. 147.  29.  F r a s e r B r o c k i n g t o n , World H e a l t h , (Edinburgh: C h u r c h i l l Livingsone, 1975), p. 177.  Background p. 501-503.  Background p. 501.  International  of the  of the Sanitary  Politics",  83 CHAPTER FOUR THE WORLD HEALTH ORGANIZATION AND THE EVOLUTION OF THE INTERNATIONAL HEALTH REGIME  The problems o f economic, s o c i a l and t e c h n i c a l development f o r a l l n a t i o n s have e v o l v e d i n such a way s i n c e 1945 as t o make o r g a n i z e d international cooperation across a l l b a r r i e r s of p o l i t i c s , i d e o l o g y and c u l t u r e a sheer n e c e s s i t y i f each o f them i s t o reap t h e b e n e f i t s o f t h e new developments i n science and technology without c r e a t i n g tensions and r i s k s . Dag Hammarskjold INTRODUCTION AND EPIDEMIOLOGICAL REVIEW In 1945, t h e y e a r o f t h e f o r m a t i o n o f the World H e a l t h O r g a n i z a t i o n , t r a d i t i o n a l epidemic d i s e a s e s t h a t had sparked the i m p l e m e n t a t i o n  o f q u a r a n t i n e were r e c e d i n g , w i t h  c o n t a g i o u s d i s e a s e s a r i s i n g t o take t h e i r p l a c e .  other  The l i s t o f  epidemic d i s e a s e s o f t h e l a s t c e n t u r y - c h o l e r a , t h e plague, and yellow fever - was r e v i s e d now to include smallpox, malaria, influenza, and p o l i o m y e l i t i s .  typhus,  The c o n t r o l of the more  s o c i a l diseases such as t u b e r c u l o s i s and venereal diesases was now pursued by the Western n a t i o n s .  1  As p r e v i o u s methods of  d i s e a s e containment had not proven e f f e c t i v e i n p r e v e n t i n g epidemic  invasions, i t was decided t o embark upon a new course  of a c t i o n , a epidemic  foci  s e l e c t p o l i c y o f e r a d i c a t i o n , t o e l i m i n a t e the o f c e r t a i n d i s e a s e s a t t h e i r source.  Before  World War Two there had not been adequate s c i e n t i f i c knowledge t o embark upon such a campaign.  Instead, attempts were made  84 only to contain disease.  Quarantine had been used as a means  of p r o t e c t i n g the developed European countries from the of A s i a n  disease.  Yet  these  measures had  ineffective  i n achieving t h e i r  increasing  criticism  international With  goal,  for their  they  not  only  spread proved  a l s o came under  detrimental  effects  on  trade.  the  establishment  of  international health  organizations at the turn of the century, attempts were made to move beyond a p u r e l y d e f e n s i v e response. been s c i e n t i f i c a l l y the  spread  public  confirmed  that the best method to c o n t r o l  of epidemic disease  health  was  f a c i l i t i e s , thereby  r e s i s t e n c e to disease.  t o develop a  For t h i s s o l u t i o n t o be enacted  and  countries,  which more often than not was  diseases  resources  had  needed  originated.  f o r the  developing  where the spread  They  lacked  of  basic  t o implement such a program on t h e i r own.  The  of the League of Nations  public international health  initiating standards  a i d was  both  the  Health Organization reorient  country's  increasing i t s internal  technical  these  financial  I t had by t h i s t i m e  had  in this  attempted to direction  by  s t u d i e s t h a t determined g u i d e l i n e s f o r minimum  of hygiene, nutrution,  and s a n i t a t i o n services. This  organization, unfortunately, lacked the resources and power t o put any  political  of t h e i r s t u d i e s ' c o n c l u s i o n s i n t o g e n e r a l  practice. Despite Organization's  the  progressive  stated goals  nature  of the  to promote the  World  Health  welfare  of a l l  85 c i t i z e n s through the s t r e n g t h e n i n g of the h e a l t h s e r v i c e s of member  states,  progress  international  only slowly  h e a l t h c o l l a b o r a t i o n was  from i t s former concern  with  to  defense  against the spread of disease toward the establishment of these newer i d e a l s . required  of  Although the WHO an  embraced the idea that more was  international  health  o r g a n i z a t i o n than  an  i n t e r n a t i o n a l system of defense a g a i n s t common d i s e a s e , the initial  a c t i o n s of i t s I n t e r i m Commission were v e r y much a  continuation of the t r a d i t i o n a l work of previous  international  health  primarly  organizations.  epidemiological outbreaks  of  These d u t i e s  r e p o r t i n g and  contagious  centered  on  p r o v i d i n g emergency a i d f o r  disease  i n t e r e s t s of the more developed  when they  nations.  threatened  the  For instance, during  i t s b r i e f h i s t o r y , c h o l e r a had a g a i n broken out i n Egypt and immediate a c t i o n was reached  needed t o c o n t a i n i t s spread b e f o r e i t  the Mecca p i l g r i m a g e s .  The Mecca p i l g r i m a g e s were  a g a i n a source o f i n t e r n a t i o n a l concern and a c t i o n because of t h e i r p o t e n t i a l t o spread d i s e a s e n o r m a l l y e p i d e m i c o n l y i n A s i a to the uninfected West. During  i t s two  World Health  year tenure the Interim Commission of the  Organization was  not  concerned with e r a d i c a t i n g  contagious diseases at t h e i r source, only with containing t h e i r spread t o u n i n f e c t e d areas.  T h i s a c t i o n was  again required  when I t a l y and Greece, i n t h e i r weakened condition, succumbed to  an  extensive  attention  attack  from the  of  malaria.  Commission,  They  received  even t h o u g h t h e  quick  malaria  86 i n f e s t a t i o n i n these two Western developed c o u n t r i e s was not n e a r l y as severe as i t was i n many o f t h e l e s s e r members o f the WHO. strong  developed  This point e s p e c i a l l y demonstrates the  c o n t i n u i t y between  t h e WHO  organizations. For the f i r s t  and p r e v i o u s  health  few y e a r s t h e programs o f t h i s  organization continued t o center on providing emergency r e l i e f and p r o t e c t i v e r e g u l a t i o n t o the developed countries. PROGRAMS OF DISEASE ERADICATION I t was n o t u n t i l i t s second decade t h a t t h e WHO was t o embark upon a program of disease eradication. I t f i r s t out m a l a r i a a t t h e E i g h t h  singled  World H e a l t h Assembly and l a t e r  embarked upon an i n t e r n a t i o n a l e f f o r t t o e l i m i n a t e the scourge of  smallpox  efforts  a t t h e E l e v e n t h Assembly.  was an abysmal  failure;  e v e n t u a l l y a complete success.  The f i r s t  t h e second  o f these  was t o prove  The reasons f o r one program's  e f f e c t i v e n e s s and the other's f a i l u r e are very much r e l a t e d t o the  scientific  natures  o f t h e two d i s e a s e s .  Malaria i s  spread from person t o person, through an i n t e r m e d i a t e agent, the mosquito.  As t h e r e i s no v a c c i n e f o r m a l a r i a ,  spraying of i n s e c t i c i d e vector. medical, against  repeated  i s necessary  to destroy the insect  Few o f t h e l e s s e r developed  n a t i o n s possessed the  t e c h n i c a l , or f i n a n c i a l resources t o guard constantly a reoccurrence  of this  disease.  As w e l l ,  social  customs, such as nomadic migrations and the s e c l u s i o n of women g r e a t l y increased the d i f f i c u l t i e s involved i n disease control. A f u r t h e r d i f f i c u l t y was posed by the tendency of mosquitoes  87 t o become r e s i s t a n t t o i n s e c t i c i d e s , which i n any case were only e f f e c t i v e f o r a short duration. t h i s campaign, however, was a f t e r the i n i t i a l  What was  most damaging to  the complacency t h a t developed  outbreak was  under c o n t r o l and  contained.  Constant v i g i l e n c e i s required to prevent a reoccurrence d i s e a s e i n e p i d e m i c form.  Yet a s u b s t a n t i a l p o r t i o n of the  c o u n t r i e s where the d i s e a s e accept  the  was  endemic were r e l u c t a n t to  i m p l i c a t i o n s of t h i s  epidemiological  preferred, instead, to devote resources  e r a d i c a t i o n program t o implement.  program  of  global  was  storage  needle was  times  A p r o t e c t i v e vaccine  had  What was needed was a system and  innoculation.  i n hot  and  a much e a s i e r  The  vaccine  needed t o  strengthened and improved f i r s t , however, so i t could long  fact  elswhere.  Smallpox, i n comparison t o m a l a r i a ,  been i n e x i s t e n c e s i n c e 1798.  of the  climates.  be  withstand  A special bifurcated  a l s o developed under the a u s p i c i e s o f the WHO's  t e c h n i c a l research programme on  smallpox e r a d i c a t i o n and  g r e a t l y improved the e f f i c i e n c y o f v a c c i n a t i o n . demonstrated t h a t  this  I t had been  e r a d i c a t i o n from an endemic area  can  be  r e a l i z e d when eighty percent of the population i s s u c c e s s f u l l y vaccinated  within  considerably  a time  period  e a s i e r to achieve  of  five  years.  This  is  t h a n what a p p e a r s t o  be  necessary to eliminate malaria. The  World  Health  Organization  was  central  to  the  development of t h e s e programmes, p r o v i d i n g both t e c h n i c a l assistance  and  medical  personal  to  countries  that  lacked  88 adequate resources of t h e i r own.  A c e n t r a l body was needed to  c o o r d i n a t e t h e p l a n n i n g f o r t h e s e campaigns, boundaries are i l l o g i c a l parameters e r a d i c a t i o n program.  for political  w i t h i n which to conduct an  I t proved to be quite easy t o secure the  n e c e s s a r y a p p r o v a l o f s t a t e s f o r these programs, as t h e c o s t s of  e r a d i c a t i o n were often l e s s than the economic cost that the  d i s e a s e s themselves enacted i n terms o f l o s s e s t o t h e l a b o u r force.  F o r i n s t a n c e , a c c o r d i n g t o a WHO  sponsored  study,  "malaria i s the most expensive disease i n the world; i t stunts the p h y s i c a l community  and m e n t a l  growth of persons,  i n exploration of national  hampers t h e  resources,  reduces  a g r i c u l t u r a l production and impairs industry and commerce."  3  In  t h e developed c o u n t r i e s these p e s t i l e n t d i s e a s e s no  longer posed and,  a s u b s t a n t i a l health r i s k .  Most were eradicated  i f an outbreak d i d suddenly occur w i t h i n these countries,  i t c o u l d be q u i c k l y c o n t a i n e d by t h e i r w e l l - d e v e l o p e d h e a l t h c a r e systems and r e s o u r c e s .  And y e t t h e developed c o u n t r i e s  were supportive of these e r a d i c a t i o n programs.  One explanation  as t o why i s the emotional appeal of e r a d i c a t i o n programs. I t was v e r y much i n t h e s p i r i t  o f t h e U n i t e d N a t i o n s t o embark  upon such a worthwhile humanitarian venture.  Supporting such a  proposal would only enhance a developed country's i n t e r n a t i o n a l standing with the newly independent  members of the WHO.  This  no doubt was one o f t h e m o t i v a t i n g f a c t o r s behind t h e S o v i e t Union's proposal f o r a global e r a d i c a t i o n program f o r smallpox. Moreover, t h e degree  of i n t e r n a t i o n a l  t r a v e l had a l s o  89 undergone a great expansion. t o be s a f e from the s p e c t r e to  be  fast  and  quarantine.  Developed nations required t r a v e l of i n f e c t i o u s d i s e a s e s , as w e l l as  efficient  and  International t r a f f i c  of modern economic development. c o n t r o l of epidemic quarantine  free  i s one  Further,  with  by  the  of the  delays  of  foundations  d i s e a s e s and the e l i m i n a t i o n of l e n g t h y  periods.  damaged  the  E f f i c i e n t trade requires the  Tourism  was  a l s o an  economic importance to many countries. greatly  from  an  outbreak  growing  of  area  of  growing  This industry could be a  contagious  interdependence  disease.  of the  world's  economies and the emergence of m u l t i n a t i o n a l firms, operating on a g l o b a l s c a l e , d i s e a s e c o n t r o l was was  desired by the developing country, hoping to a t t r a c t such a  firm,  and  workforce  by and  the not  p o s s i b l e unhealthy THE THE  clearly desirable. It  multinational i t s e l f , willing  needing  t o expose i t s own  a  healthy  employees  to  situations.  INTERNATIONAL HEALTH REGULATORY REGIME ISSUE OF SANITARY REGULATIONS The o l d methods o f d i s e a s e containment, q u a r a n t i n e  and  b i l l s of health, were i n c r e a s i n g l y proving to be i n e f f e c t i v e as w e l l as s c i e n t i f i c a l l y outdated. One  of the f i r s t functions of  the World Health Organization had been to r e v i s e and amalgamate all  of the previous s a n i t a r y conventions,  not  proven t o be  very  effective  even though they had  in their  stated goals  of  ensuring the maximum s e c u r i t y against the i n t e r n a t i o n a l spread of d i s e a s e , w i t h a minimum amount of i n t e r f e r e n c e w i t h world traffic.  4  The  r e c e n t l y updated  version  of  the  sanitary  90  regulations, o r i g i n a l l y implemented i n 1952,  d i d not prevent an  outbreak of cholera i n Asia and the Middle East i n 1961.  There  were also constant instances of noncompliance with the sanitary regulations that not only damaged any have had,  but i n c r e a s i n g l y brought  regulations The  into  1952  several new  e d i t i o n of the s a n i t a r y r e g u l a t i o n s  contained  provisions that were a s i g n i f i c a n t improvement over Recognizing that one of the most troublesome  aspects of e a r l i e r conventions was new  the c r e d i b i l i t y of these  disrepute.  e a r l i e r versions.  the  e f f e c t i v e n e s s they might  edition  of  the  securing t h e i r r a t i f i c a t i o n ,  sanitary  code had  abandoned  the  t r a d i t i o n a l t r e a t y form.  Instead, upon becoming a member of  the WHO  of i t s C o n s t i t u t i o n ,  under A r t i c l e 22  the  sanitary  regulations were to come i n t o immediate e f f e c t , unless a state notified  the  reservations  H e a l t h Assembly  regarding  " c o n t r a c t i n g out", and  was  agreed t o by  debate r e g a r d i n g the end  was  i t was  within  n i n e months o f i t s  certain Articles.  This process, termed  suggested by the American the  Interim  delegation  Commission a f t e r a b r i e f  i t s i m p l i c a t i o n s f o r state sovereignty.  In  decided that as these regulations governed only  h i g h l y t e c h n i c a l i s s u e s they would not endanger the power of the nation state i n a s i g n i f i c a n t The WHO Regulations,  was  a l s o given, under A r t i c l e 21 of the  wide authority to draw up regulations  h e a l t h i s s u e t h a t might a r i s e . this  option.  fashion.  5  "Footnotes" are  To date i t has not used  instead  as  Sanitary  on any  new  excercised additional  91  recommendations  added on  to p r o v i s i o n s  i n the  sanitary  regulations that permit the organization e i t h e r to i n t e r p r e t or amplify  s p e c i f i c components of the regulations.  The  option to  use t h i s procedure to implement p o l i c y changes, as opposed to the more f o r m a l procedures i n A r t i c l e 21,  i s evidence of the  WHO'S e f f o r t s t o p r e s e r v e a n o n c o n t e n t i o u s r o l e i n m a t t e r s of international  health.  I f a s t a t e has o b j e c t i o n s to p a r t i c u l a r r e g u l a t i o n s , i t can  choose to adopt the regulations with reservations  specific articles.  The  against  assumption b e h i n d t h i s p r o v i s i o n i s  t h a t by a l l o w i n g s t a t e s to opt out of p a r t i c u l a r r e g u l a t i o n s for  specific  reasons  i t will  compliance o f them o v e r a l l .  6  e n c o u r a g e more  widespread  There i s , however, a t h r e e year  t i m e l i m i t on r e s e r v a t i o n s and they must be approved by  the  World Health  Assembly.  the  regulations  and  This prevents the emasculation of  ensures  that  reservations  do  not  in  fact  c o n s t i t u t e an actual r e j e c t i o n of the s a n i t a r y regulations. A r t i c l e 99 of the S a n i t a r y R e g u l a t i o n s  also allows  for  states to adopt, under " s p e c i a l arrangement", health measures i n a d d i t i o n to those p r e s c r i b e d underlying  i n the  purpose o f t h i s p r o v i s i o n  s a n i t a r y code. facilitate  the  e v e n t u a l a p p l i c a t i o n of the s a n i t a r y code i n i t s o r i g i n a l  and  complete form. particular  7  i s to  The  Special arrangements are to be u t i l i z e d when a  health  s i t u a t i o n warrants them.  For  instance,  countries that consider themselves to be at great r i s k because of t h e i r lack of p u b l i c health f a c i l i t i e s can  impose sanitary  92  p r o v i s i o n s i n excess of the regulations to protect themselves from  a contagious disease  population.  t h a t has  not  yet  infected their  In such a case, a s p e c i a l arrangement can be i n  the b e s t i n t e r e s t s of i n t e r n a t i o n a l p u b l i c h e a l t h . with  reservations,  s p e c i a l arrangements are  Again, as  l i m i t e d to  i n t e r p r e t a t i o n by the Health Assembly; i f not considered  to be  j u s t i f i a b l e , they are deemed excessive and p r o h i b i t i v e . Reservations  have proven very  u t i l i z e d by states who but,  u s e f u l over the years when  agree with the regulations i n p r i n c i p l e ,  f o r u n f o r s e e n c i r c u m s t a n c e s , are unable t o comply w i t h  them.  E t h i o p i a e s t a b l i s h e d t h i s precedent i n 1951  when i t  reported that i t would have serious d i f f i c u l t i e s complying with regulations to n o t i f y outbreaks of contagious diseases because of poor communications between the c a p i t a l and the country, although i t accepted the p r i n c i p l e s of the s a n i t a r y code. The the  advantages of contracting out are obvious.  quick  s u b m i s s i o n and  approval  It  8  allows  of the h i g h l y t e c h n i c a l  i n t e r n a t i o n a l s a n i t a r y agreements, as w e l l as f l e x i b i l i t y i n updating these regulations the  years  there  reservations,  has  to meet current  even been a d r o p  situations. i n the  norms  synonymous Organization. on  Over  number  of  as states are i n c r e a s i n g l y able to adhere to the  norms of the sanitary code i n greater d e t a i l . The  9  of  with  the the  health stated  regime goals  of  1 0  are the  not,  however,  World  Health  The norms of t h i s regime are s t i l l based l a r g e l y  p r i n c i p l e s established during  the  sanitary  conferences.  93  T h i s regime had  undergone a p e r i o d of t r a n s i t i o n , w i t h  formation of i n t e r n a t i o n a l health organizations.  the  The degree of  t h i s evolution can be seen i n the general p r i n c i p l e s that were drawn up to guide the d r a f t i n g of the new 1.  s a n i t a r y regulations:  Accurate and r a p i d n o t i f i c a t i o n are the basis of e f f e c t i v e measures against the there  should  be  a  i n t e r n a t i o n a l spread withdrawal  of  of disease  and  restrictions  on  i n t e r n a t i o n a l t r a f f i c as soon as the danger of i n f e c t i o n is 2.  passed.  Each c o u n t r y  should develop i t s i n t e r n a l r e s i s t a n c e to  disease rather than r e l y on measures taken at f r o n t i e r s . 3.  Measures taken  at  frontiers  should  be  the  minimum  compatible with the e x i s t i n g s a n i t a r y s i t u a t i o n . Excessive measures not o n l y e x e r t undue i n t e r f e r e n c e w i t h  traffic  and have s e v e r e economic consequences, but by t h e i r v e r y excess might l e a d t o d e l i b e r a t e e v a s i o n of the s a n i t a r y code and thereby defeat the o r i g i n a l object. While these p r i n c i p l e s show the continued norms of the  e a r l i e r h e a l t h regime,  presence of the  the p r e v e n t i o n  of  the  spread of d i s e a s e w i t h a minimum amount o f i n t e r f e r e n c e w i t h international traffic,  they a l s o c o d i f y two  new  concepts i n  i n t e r n a t i o n a l h e a l t h p r o t e c t i o n o r i g i n a t i n g from the work of earlier  i n t e r n a t i o n a l health organizations.  first  i s the  value of epidemiological n o t i f i c a t i o n i n containing the  spread  of disease;  The  the second i s the value of i n c r e a s i n g a  i n t e r n a l r e s i s t a n c e to combat disease i t s e l f .  country's  94  To f u r t h e r the f i r s t of the above p r i n c i p l e s , a l l members were r e q u i r e d t o t r a n s m i t a c c u r a t e and r a p i d n o t i f i c a t i o n on any outbreaks o f s p e c i f i c d i s e a s e s .  At the formation  of the  WHO these included yellow fever, cholera, plague, and smallpox. This l i s t was a reduction i n the number of diseases covered by the previous agreement of 1926. The second p r i n c i p l e a d v o c a t i n g  c o u n t r i e s develop t h e i r  own i n t e r n a l r e s i s t e n c e t o disease forms the j u s t i f i c a t i o n f o r the many t e c h n i c a l and d i r e c t a s s i s t a n c e programs.  T h i s new  development i s s t i l l not t o t a l l y accepted by a l l members of the organization, but i t was approved by the t e c h n i c a l e l i t e s , who put t h i s p o l i c y i n t o p r a c t i c e . adoption  of t h i s  p o l i c y i s a f u r t h e r d e m o n s t r a t i o n o f the  abandonment of quarantine The  I t was a l s o s i g n i f i c a n t as the  as a p u b l i c health measure.  t h i r d p r i n c i p l e r e a s s e r t s t h e norms o f t h e e a r l i e r  health regime by s t r e s s i n g that the health measures  contained  i n the regulations are the maximum allowable. Under the WHO, i t was s t i l l  an important component of the regime t o preserve the  free flow of i n t e r n a t i o n a l trade. The  r e g u l a t i o n s themselves were l a r g e l y concerned  with  h a l t i n g the spread of disease through the p r o v i s i o n at a i r p o r t s and p o r t s o f p r o p e r m e d i c a l f a c i l i t i e s t o t r e a t communicable diseases.  The s a n i t a r y r e g u l a t i o n s c o n s t i t u t e d t h e maximum  procedures allowable  i n terms of demanding health c e r t i f i c a t e s  and imposing q u a r a n t i n e s ,  a n y t h i n g above t h e s e p r o v i s i o n s i s  deemed t o be an " e x c e s s i v e measure" and i s s u b j e c t t o review by  95  the organization.  The WHO  assumes that the s a n i t a r y provisions  c o n t a i n e d i n i t s r e g u l a t i o n s w i l l be e f f e c t i v e i n c o u n t e r i n g the spread o f d i s e a s e , and t h a t a l o n g w i t h a r e g u l a r flow of information  regarding  d i s e a s e s , they  the  status  w i l l discourage  of these  communicable  the deployment of  excessive  measures. The r e g u l a t i o n s can be viewed as p a r t of an e v o l u t i o n a r y process.  Bills  of  health  were f i n a l l y  abolished  and  the  process of contracting out made the adoption of regulations and t h e i r subsequent r a t i f i c a t i o n  much e a s i e r .  1 1  This enabled more  s t a t e s t h a n ever b e f o r e t o become s i g n a t o r i e s t o t h i s s e t of sanitary  regulations.  For  the  first  time the  sanitary  regulations were i n complete harmony with modern p u b l i c health and  epidemiological theories.  Quarantine had been replaced  a system of epidemiological i n t e l l i g e n c e and NON-COMPLIANCE AND Despite code,  notification.  THE SANITARY REGULATIONS  these evolutionary  s t a t e s continued  myriad of reasons.  advances i n the  to v i o l a t e  1951  sanitary  these r e g u l a t i o n s  others p r e f e r r e d t h e i r own sanitary  code.  noncompliance:  for a  Some states were not able to implement the  r e g u l a t i o n s , l a c k i n g the adequate t e c h n i c a l r e s o u r c e s ,  the  by  while  s o l u t i o n s to the ones suggested i n  There  notification  are of  two an  particular outbreak  of  diseases and the imposition of excessive measures.  areas  of  reportable The  extent  of noncompliance has been extensive i n c e r t a i n areas, enough to question  the  feasibility  of the h e a l t h regime i t s e l f .  The  96  successful functioning of the health regime i s based, i n part, on states n o t i f y i n g the organization of outbreaks of contagious diseases.  A i d and t e c h n i c a l resources can then be concentrated  i n t h i s area t o enact a r a p i d s o l u t i o n t o the problem. states f a i l to n o t i f y , the spread of disease can grow and  If  this,  i n t u r n , prompts s t a t e s t o impose e x t r a measures t o p r o t e c t themselves  from  Ironically,  f a i l u r e t o n o t i f y the outbreak of a p a r t i c u l a r  disease  often  is  excessive  an  apparently  motivated  measures.  by  uncontrollable  fear  of  I t a p p e a r s t o be  the  epidemic.  imposition  i n a state's  i n t e r e s t both t o comply and not to comply w i t h the regulations.  of best  sanitary  To comply with them allows f o r quick a c t i o n  and  promotes confidence i n the regime, but also e n t a i l s the r i s k of other states imposing excessive measures against t h e i r trade or nationals. The state  a p p l i c a t i o n of s a n i t a r y r e g u l a t i o n s  i s balanced against  concerns.  i t s economic and  for  a  nation  administrative  R e p o r t i n g the outbreak of a n o t i f i a b l e d i s e a s e i s  regarded by many d e v e l o p i n g c o u n t r i e s as the mark of a T h i r d World c o u n t r y and e n t a i l s a l o s s of p r e s t i g e .  Admitting  the  e x i s t e n c e of one of t h e s e p e s t i l e n t d i s e a s e s can a l s o g r e a t l y harm the t o u r i s t industry of a country, which often constitutes a large percentage of a developing country's revenue. The  WHO  12  i s v i r t u a l l y powerless to stop these v i o l a t i o n s ;  as an i n t e r n a t i o n a l o r g a n i z a t i o n i t has no power t o f o r c e the compliance of s t a t e s r e g a r d i n g  i t s regulations.  The most i t  97  can do i s p u b l i s h the v i o l a t i o n s t o b r i n g the p r e s s u r e of the i n t e r n a t i o n a l system upon a s t a t e i n an e f f o r t t o f o r c e i t s compliance.  There are v e r y  strict  r e g u l a t i o n s as t o what  epidemiological information can be transmitted.  Under A r t i c l e  E l e v e n of the S a n i t a r y R e g u l a t i o n s , the WHO  may  information  national  ministries confirmed  from of  authorized  members.  13  sources;  Even  the  when the  only p u b l i s h health  organization  has  information of the existence of a n o t i f i a b l e disease  from other r e l i a b l e sources, another  country,  i t is  antagonizing a member.  such as a medical delegation from reluctant  The WHO  to  act  for  fear  of  p r e f e r s to keep correspondence  at the l e v e l of n a t i o n a l health m i n i s t r i e s ; accusing a country of v i o l a t i n g the s a n i t a r y regulations would undoubtedly b r i n g the more p o l i t i c a l f o r e i g n m i n i s t r i e s i n t o the d i s p u t e . organization  feels  noncompliance. sources,  i t is  When  counterproductive  i t receives  The  to p u b l i c i z e  information  from  other  i t attempts t o persuade the c o u n t r y i n v i o l a t i o n t o  n o t i f y on i t s own  accord.  15  In a p a r t i c a l a r case where the r e s p e c t o f the D i r e c t o r General  was  high,  the WHO  has  reported  the e x i s t e n c e  of a  n o t i f i a b l e disease, despite that country's f a i l u r e to admit the existence  of t h i s  situation.  During  the  1970  outbreak  of  c h o l e r a i n the sub-Sahara r e g i o n of A f r i c a , Guinea r e f u s e d t o notify  the  outbreak  of  this  disease.  outbreak p a r t i c u l a r l y severe, i t was  Not  only  was  this  also the f i r s t outbreak of  t h i s h i g h l y s u s c e p t i b l e r e g i o n i n a number of years.  After  98  repeated  requests  by t h e D i r e c t o r  General  t o r e p o r t the  e x i s t e n c e o f t h i s d i s e a s e , he f i n a l l y announced i t under the authority of A r t i c l e Two of the Sanitary  Regulations.  This one example has, so f a r , been the only instance where the  organization  had r e p o r t e d  the existence  a g a i n s t t h e wishes o f a member s t a t e . unique c o n d i t i o n s were p r e s e n t .  of a  disease  I n t h i s case,  several  First,  there  was s e r i o u s  concern over the p o s s i b i l i t y of a new outbreak of cholera i n a uninfected repeated  population  w i t h poor m e d i c a l s e r v i c e s .  e f f o r t s t o have t h e o f f e n d i n g  country  Second,  n o t i f y the  o r g a n i z a t i o n o f i t s t r u e s t a t u s were met w i t h s i l e n c e . third,  And  t h e D i r e c t o r General a t t h i s time, Dr. M. G. Candau,  enjoyed great respect and authority w i t h i n the o r g a n i z a t i o n . T h i s developement i s a f u r t h e r s i g n o f t h e e v o l u t i o n i n t e r n a t i o n a l health regime.  16  ofthe  Where once o f f i c i a l s would only  have a c t e d w i t h t h e d i r e c t a u t h o r i t y o f member s t a t e s , they a c t e d i n t h i s i n s t a n c e upon t h e i r own a u t h o r i t y , u s u r p i n g the t r a d i t i o n a l power of the nation state t o a degree. The  World H e a l t h  Organization  recognizes  t h a t i n many  cases noncompliance i s not due t o intransigence on the part of a member, equipment  b u t t h e l a c k o f adequate r e s o u r c e s and p e r s o n n e l  regulations.  1 7  Many  t o comply  of the health  with  i n terms o f  the sanitary  problems  that the  r e g u l a t i o n s r e f e r t o , such as t h e containment o f c o n t a g i o u s diseases, cannot be solved by mere r e g u l a t i o n alone.  The World  H e a l t h O r g a n i z a t i o n a p p r e c i a t e s t h a t t h e h e a l t h problems the  99  developing  s t a t e s f a c e are o u t s i d e the scope of r e g u l a t i o n .  What i s needed instead i s improvements i n b a s i c health care and s a n i t a t i o n services. Another reason behind the f a i l u r e of s t a t e s to inform the WHO  of an outbreak o f a n o t i f i a b l e d i s e a s e i s t h e i r f e a r of  excessive measures that other states might u n j u s t i f i a l b y place upon t h e i r trade or t r a v e l l i n g nationals. have reason  In many cases states  t o worry over the p o s s i b l e i m p o s i t i o n of  these  measures as they had o c c u r r e d i n the p a s t w i t h some degree of frequency.  For instance, i n 1966  an outbreak of c h o l e r a . imposed  extra  Iraq duly n o t i f i e d the WHO  Surrounding  restraints  on  repeated appeals from the WHO,  countries  traffic  from  of  immediately  Iraq.  Despite  these nations refused to respond  t o t h e s e charges or t o remove the e x c e s s i v e measures.  Four  years l a t e r a s i m i l a r s i t u a t i o n arose with regards to I s r a e l , which had a l s o n o t i f i e d the WHO As  a  result  of  the  of a cholera outbreak.  unfair imposition  of  excessive  measures, countries have taken to minimizing the appearance of an outbreak i n o r d e r t o a v o i d p o s s i b l e r e t a l i a t o r y measures. Information submitted  regarding  to the WHO  the  status  of  notifiable  has often been imcomplete, inadequate,  has only reported a minimum number of cases. would prematurely  or  As w e l l , states  announce that they were free of disease i n an  e f f o r t to avoid the damaging e f f e c t s of excessive The WHO  diseases  measures.  18  often had information from other r e l i a b l e sources that  contradicted  the  i n f o r m a t i o n t h a t a member r e p o r t e d .  Yet  100  again,  under  Article  Eleven  of the Regaulations,  i t was  p o w e r l e s s t o i s s u e any o f t h i s a l t e r n a t i v e i n f o r m a t i o n .  The  o r g a n i z a t i o n a l s o understood t h e predicament many o f these i n f e c t e d s t a t e s were i n and d i d not want f u r t h e r t o a l i e n a t e them by challenging the v a l i d i t y of t h e i r  information.  In most cases excessive measures were i r r a t i o n a l responses on the part of states, who g r e a t l y feared an outbreak of one of these p e s t i l e n t diseases. excessive  measures  As w i t h  reassured  quarantine states  i n t h e past,  by p r o v i d i n g  a  psychological b a r r i e r against an i n f e c t i o u s disease that could i n f l i c t great harm upon them.  Yet excessive measures were not  the best means of p r o t e c t i o n against these p e s t i l e n t diseases; i n s t e a d s t a t e s needed t o promote t h e i n t e r n a l development o f good p u b l i c h e a l t h and s a n i t a t i o n f a c i l i t e s .  The c o u n t r i e s  that most often u t i l i z e d excessive measures were the ones with l e s s advanced p u b l i c h e a l t h care systems and t h e r e f o r e  felt  themselves t o be at greater r i s k . The WHO was v i r t u a l l y powerless t o stop these i n f r a c t i o n s , despite the f a c t that t h e i r continued use, g r e a t l y weakened the c r e d i b i l i t y o f t h i s o r g a n i z a t i o n and t h e h e a l t h regime. WHO  published  the imposition  of excessive  The  measures i n the  Weekly Epidemiological Report i n an attempt to discourage  their  u t i l i z a t i o n and o f f e r e d t o use i t s "good o f f i c e s " t o t r y and settle  disputes  officially  that  provided  Regulations,  arose  over these  f o r under A r t i c l e  measures.  This i s  106 o f t h e S a n i t a r y  a l t h o u g h t h e m a t t e r i s u s u a l l y d e a l t w i t h under  101  l e s s formal conditions.  The overwhelming majority of disputes  are handled a t the t e c h n i c a l l e v e l ,  between respective health  administrators and o f f i c i a l s of the WHO.  19  A r t i c l e 106 does provide,  however, f o r a more formalized  method o f s e t t l i n g d i s p u t e s : "any such d i s p u t e which has not been thus s e t t l e d  (through  the use of WHO'S good o f f i c e s ) , may  by n a t i o n a l a p p l i c a t i o n , be r e f e r r e d by any s t a t e concerned to the  I n t e r n a t i o n a l Court of J u s t i c e f o r d e c i s i o n . "  This  p r o v i s i o n has only been u t i l i z e d once, i n 1970 with an incident i n v o l v i n g Turkey, Romania, and B u l g a r i a .  As a r e s u l t o f t h e  cholera epidemic of the 1960s many countries sought t o impose severe  frontier  neighbouring  restrictions  countries suspected  on p e r s o n s and goods of harbouring  cholera, despite  the f a c t t h a t t h i s was p r o h i b i t e d i n t h e r e g u l a t i o n s . most o f t h e c o u n t r i e s t h a t f a c e d t h i s WHO'S  good  Regulations.  offices,  Turkey  I t complained  invoked  from  While  s i t u a t i o n appealed t o Article  that Bulgaria  106 o f t h e  and Romania had  c l o s e d t h e i r f r o n t i e r s t o T u r k i s h convoys o f food produce and were r e q u i r i n g v a c c i n a t i o n c e r t i f i c a t e s  from t h e i r nationals,  despite that f a c t that Turkey had been declared infected. measures were n o t p e r m i t t e d  under t h e S a n i t a r y  The  Regulations.  T h i s m a t t e r was q u i c k l y s e t t l e d a f t e r i t was brought t o t h e official  level,  where  t h e more p o l i t i c a l  departments o f  governments, the foreign a f f a i r s bureaus, became involved.  The  o f f e n d i n g c o u n t r i e s withdrew t h e o b j e c t i o n a b l e measures t o a v o i d adverse p u b l i c i t y .  2 0  Although i n t h i s f i r s t  instance  102  A r t i c l e 106  achieved  a successful r e s o l u t i o n of the dispute i t  has not been employed since, no doubt r e f l e c t i n g the desire of health m i n i s t r i e s to keep health disputes at a t e c h n i c a l l e v e l , avoiding the more p o l i t i c a l solutions. The  reappearance of cholera i n epidemic form i n the 1960s  i n A f r i c a and A s i a had a f a r r e a c h i n g  e f f e c t upon the h e a l t h  regime; i t caused a serious revaluation of the aims and methods of  this  organization.  Widespread  noncompliance  with  the  sanitary regulations, the f a i l u r e of states to n o t i f y outbreaks of c h o l e r a , as w e l l as the p r e v a l e n t use o f e x c e s s i v e meaures had  combined t o c r e a t e a s e r i o u s problem of c r e d i b i l i t y f o r  t h i s regime.  F a i l u r e s t o n o t i f y outbreaks o f c h o l e r a were so  predominant t h a t they l e d t o d i s c u s s i o n s of i t b e i n g removed from the l i s t of n o t i f i a b l e diseases.  I t was  decided,  however,  that t h i s measure would only exacerbate the s i t u a t i o n , the requirement to n o t i f y encouraged some it  should  remain.  21  The  entered  as  degree of compliance  e r a d i c a t i o n campaign f o r malaria  a l s o e x p e r i e n c e d s u b s t a n t i a l setbacks. had  and  had  Several states that  the "maintenance" or "consolidation" phases of  the  programme, where they were declared free or nearly free of the disease,  suddenly experienced major outbreaks.  these developments the  22  In l i g h t  Twentieth World Health  of  Assembly  recommended a r e e x a m i n a t i o n of the e n t i r e s t r a t e g y .  It  was  gradually r e a l i z e d that e r a d i c a t i o n programmes were doomed to failure —  the countries of the developing  the r e s o u r c e s  world d i d not posses  t o s u c c e s s f u l l y c a r r y out such a task, and  the  103  developed countries are u n w i l l i n g to contribute these resources to them. EVOLUTION WITHIN THE WORLD HEALTH ORGANIZATION Advances i n the two e r a d i c a t i o n programs had occurred when states  concentrated  their  resources  i n h e a l t h care.  Once  r e s u l t s were a c h i e v e d t h e i r a t t e n t i o n to t h i s area weakened however, and  setbacks  occurred.  These i n c i d e n t s and  the  g e n e r a l f a i l u r e of the s a n i t a r y r e g u l a t i o n s t o generate  the  2 3  compliance of s t a t e s and c o n t r o l the spread of d i s e a s e was  to  l e a d t o major i n n o v a t i o n s i n the p o l i c i e s and o r i e n t a t i o n of the World Health Organization. I t had become c l e a r i n the l a t e 1960s t h a t i n the near future  e r a d i c a t i o n was  contagious diseases.  impossible  As such,  i t was  f o r the  majority  of  decided to embark upon a  p o l i c y of "epidemiological surveillance".  Recognizing that the  i m p o r t a t i o n o f e p i d e m i c d i s e a s e s c o u l d not be h a l t e d i t was decided  to concentrate  coordinating,  and  resources  on  notifying,  assessing,  c o n t r o l l i n g a l l communicable diseases,  a t the n a t i o n a l and a t the i n t e r n a t i o n a l l e v e l .  both  I t was hoped  through t h i s p r o c e s s t h a t e a r l y containment o f d i s e a s e would become p r o g r e s s i v e l y more p l a u s i b l e ; s u c c e s s f u l disease control was  t o be a c h i e v e d through a t t r i t i o n , r a t h e r than by a d i r e c t  assult. World  2 4  T h i s p o l i c y was  Health  Sanitary  Assembly  and  i n a u g e r a t e d a t the t w e n t y - f i r s t resulted  in a  revision  of  the  Regulations.  Changes i n the 1971  e d i t i o n of the r e g u l a t i o n s i n c l u d e d  104  the a b s o r p t i o n of the I n t e r n a t i o n a l Quarantine Global  Epidemiological  "International  S u r v e i l l a n c e Bureau.  Sanitary  Regulations"  " I n t e r n a t i o n a l Health Regulations." d i s e a s e " was regulation  Bureau by the  was  also  changed  to  dropped and the number o f d i s e a s e s s u b j e c t t o  was  reduced  to four,  as typhus was  policing"  method  approach.  The  of d i s e a s e 1970s  no  longer  More s i g n i f i c a n t l y ,  changes are a development away from the narrow,  cooperative  name  The term "quarantinable  considered a serious health hazard.  "sanitary  The  was  these  legalistic  c o n t r o l to a to witness  a  more major  evolution i n the o r i e n t a t i o n of the World Health Organization and the I n t e r n a t i o n a l Health Regime. r e g u l a t i o n s had not been e f f e c t i v e  I t had been r e a l i z e d that i n e r a d i c a t i n g o r even  c o n t r o l l i n g the spread of disease i n the past. t r e n d i n the WHO regulations.  Thus, a growing  was t o employ reccommendations i n s t e a d o f  In f a c t , there has not been a new r e g u l a t i o n f o r  fifteen years.  2 5  I t had been l e a r n e d t h a t the b e s t method of  combating world health problems was to create e f f i c i e n t health services  i n a l l countries.  recognized possessed  that  r e g u l a t i o n s were of no use u n l e s s  the c a p a b i l i t y  resources.  The World H e a l t h Assembly had  In o r d e r  i n terms o f f i n a n c i a l  f o r t h i s t o occur,  position  can  be  seen  i n the  and h e a l t h  t h e r e had t o be a  change i n the p o l i c i e s of the o r g a n i z a t i o n . this  states  The o r i g i n s of  realization  of the  limitations  o f t h e f o r m e r s t r a t e g i e s o f r e g u l a t i o n and  eradication.  What was v i t a l l y needed was a program whereby the  105  WHO would p r o v i d e d i r e c t t e c h n i c a l a s s i s t a n c e t o i t s member states.  This p o s i t i o n was t o only slowly gain support w i t h i n  the o r g a n i z a t i o n ; but by 1975 and t h e c o n f e r e n c e on P r i m a r y Health Care at Alma Ata, i t was f i r m l y i n place. The  explanation  the WHO i s t w o - f o l d .  In the f i r s t i n s t a n c e the WHO was s u b j e c t  to the same pressures decolonization. the  as the United Nations was as a r e s u l t of  A large i n f l u x of developing  organization,  facilities.  f o r the e v o l u t i o n i n the o r i e n t a t i o n of  most  lacking  adequate  nations  entered  public  health  The r e g u l a t i v e aspects of the organization d i d not  i n t e r e s t t h e s e s t a t e s t o a l a r g e e x t e n t as they d i d not have substantial imposition  trade  i n t e r e s t s that  of excessive  would be hampered by t h e  measures.  s u r v e i l l a n c e no doubt provided  While  epidemioligcal  them with some benefits,  these  countries had never known a period without a serious epidemic. A r r e s t i n g t h e spread o f a s i n g l e d i s e a s e  would not cause a  s u b s t a n t i a l increase i n the health of t h e i r populations.  What  was needed was the p r o v i s i o n of basic medical and health  care  improving the q u a l i t y of l i f e f o r a l l c i t i z e n s , slowing  as w e l l as  the spread of disease.  T h i s change i n o r i e n t a t i o n was not w e l l r e c e i v e d by the members  of the developed  states.  Their  goals  f o r the  organization d i f f e r e d d r a m a t i c a l l y from those of the developing states.  Their i n t e r e s t i n the health regime was to c o n t r o l the  spread of p e s t i l e n t diseases from the l e s s developed countries, while l i m i t i n g the r e s t r i c t i o n s placed upon i n t e r n a t i o n a l trade  106  and t r a v e l , the sampe p r i n c i p l e s they supported at the sanitary conferences. reduction  of  While  the e r a d i c a t i o n  i t s scope  was  clearly  o f d i s e a s e and i n the  the  interests  of  i n t e r n a t i o n l t r a v e l and had a c e r t a i n emotional appeal f o r the developed  states,  they  were n o t  willing  to f i n a n c e the  development of the T h i r d World's health i n f r a s t r u c t u r e . While the members of the Executive Board of the WHO,  were  not a l l pleased with the d i r e c t i o n the organization was taking w i t h the i n c r e a s i n g l y v o c a l pronouncements of the d e v e l o p i n g states, they came as the policy-making body of the organization to was  accept the v a l i d i t y contained i n some of these demands.  It  r e a l i z e d by several members of the Executive Board that a  change i n p o l i c y was necessary as they were genuinely committed to  the  ideals  expressed  i n the  original  g o a l s of  this  organization. Despite the objections on the p a r t of c e r t a i n states and a few members of the Executive Board, program i n the mid-1970s.  the WHO  launched t h i s  The beginnings of t h i s new  new  stage i n  i n t e r n a t i o n a l h e a l t h c a r e can be seen by the s e l e c t i o n of a new Director-General, Dr. H. Mahler r e p l a c i n g Dr. M. G. Candau, had h e l d t h i s o f f i c e f o r over twenty y e a r s .  The new  who  Director  G e n e r a l had a d i s t i n c t v i s i o n f o r the o r g a n i z a t i o n , which he was determined to see f u l f i l l e d . the WHO  was  During i t s f i r s t  twenty-years  primarily a multilateral institution,  concerned  l a r g e l y w i t h campaigns a g a i n s t s p e c i f i c d i s e a s e s , f o l l o w i n g l a r g e l y the lead of the developed countries who  set i t s agenda.  107  Accordingly,  the development of systematic  health care was  r e s p o n s i b i l i t y and concern of member states. who,  The United  the  States  because of i t s t e c h n i c a l expertise and s i g n i f i c a n t budget  c o n t r i b u t i o n , was  perhaps the most i n f l u e n t i a l state, sought to  ensure that the organization's  a c t i v i t i e s were l i m i t e d to  problems of p u b l i c health and preventative medicine.  The  d i d not want the organization to become involved i n any way the area of s o c i a l i z e d m e d i c i n e .  the U.S. in  As a large number of states  27  from the T h i r d World j o i n e d the  organization,  however, i t  became i n c r e a s i n g l y accepted by the e x e c u t i v e board t h a t the WHO  should  provide  assistance  s e r v i c e s of member s t a t e s .  i n strengthening  health  2 8  T h i s movement w i t h i n the o r g a n i z a t i o n was c a l l s f o r a New  the  l i n k e d t o the  I n t e r n a t i o n a l Economic Order i n the General  Assembly of the U n i t e d Nations.  In h i s 1976 Annual Report t o  the World Health Assembly, Mahler embraced t h i s movement  and  referred  the  to  i t s appeal  to  the  WHO,  "to  intensify  i n t e r n a t i o n a l e f f o r t aimed at improving b a s i c health conditions i n developing  c o u n t r i e s . . . p r i m a r i l y t o the p r e v e n t i o n  of  diseases and m a l n u t r i t i o n by providing primary health services to the communities, i n c l u d i n g maternal and c h i l d health as w e l l as  family welfare."  2 9  Mahler went on t o suggest t h a t  the  General Assembly had v i n d i c a t e d the stance the WHO  had  already  embraced, having learned from i t s mixed experience  with  disease  eradication  the  need t o b u i l d  up  local  health services  i m p r o v i n g the s o c i a l and economic systems of the  by  developing  108  countries.  u  The New by  I n t e r n a t i o n a l Health Order was  p r o v i d i n g what was  termed "primary  c i t i z e n s of the world. t h i s program was  to be  implemented  h e a l t h c a r e " to a l l  The p l a n of a c t i o n f o r implementing  termed "Health f o r A l l by the Year 2000".  The  g o a l s of t h i s program were q u i t e a m b i t i o u s ; they c a l l e d f o r a global  m o b i l i z a t i o n of h e a l t h r e s o u r c e s ,  whereby the  t a r g e t of governments i n c o o p e r a t i o n w i t h the WHO  main  was  the  attainment of the highest l e v e l of health f o r every i n d i v i d u a l , which would a l l o w them t o l e a d a s o c i a l l y and productive l i f e . century that: and  referral  The WHO  3 1  economically  wants to ensure by the turn of the  a l l people have access to e s s e n t i a l health care facilities;  a l l governments w i l l have assumed  o v e r a l l h e a l t h r e s p o n s i b i l i t y f o r t h e i r people; everyone had a c c e s s t o s a f e d r i n k i n g water and s a n i t a t i o n f a c i l i t i e s ; a l l are adequately  nourished;  that a l l c h i l d r e n w i l l be  immunized  a g a i n s t the major i n f e c t i o u s d i s e a s e s ; c o n t r o l w i l l e x i s t of the major communicable diseases; and, f i n a l l y , e s s e n t i a l drugs will  be a v i a l a b l e t o a l l .  3 2  The  aim  of the program i s t o  provide health care at the l o c a l l e v e l , and i t was  designed to  be adapted by each c o u n t r y t o meet t h e i r s p e c i f i c needs.  The  WHO  had  realized  providing  the  t h a t i n the past  most  i t was  appropriate h e a l t h care  guilty  of  not  advice  to  the  d e v e l o p i n g c o u n t r i e s ; u n i v e r s a l models, based l a r g e l y on the experiences failure.  3 3  of  the  developed  c o u n t r i e s were doomed  to  109  This movement can be interpreted as a return to the i d e a l s contained  i n the c o n s t i t u t i o n of the WHO  state of complete p h y s i c a l , mental, and not  merely  the  absence  of  enjoyment of the highest  disease  or  that:  s o c i a l well-being infirmity,  a t t a i n a b l e standard  renewed i n t e r e s t i n t h e s e aims was  c o n v i c t i o n that health care was  and  the  The reason  3 4  the  growing  a fundamental s o c i a l r i g h t , and  the b e l i e f that national governments s h a l l be responsible creating  the  principles  conditions  have g r a d u a l l y  and  of health i s one  of the fundemental r i g h t s of every human b e i n g . behind the  health i s a  for i t s implementation. become a  norm  f o r most  for  These of  the  i n d u s t r a l i z e d s t a t e s and were e v e n t u a l l y t r a n s f e r r e d t o the international  level.  3 5  Despite the high i d e a l s of t h i s program i t has not been a total  s u c c e s s i n terms of i t s i m p l e m e n t a t i o n .  stated that  i t was  When Mahler  r e g r e t t a b l e t h a t members, "spend  three  quarters of the health budget on h i g h l y sophisticated, diseaseoriented  institutional  care  of i n d i v i d u a l patients i n c a p i t a l  c i t i e s - l e a v i n g l a r g e p a r t s o f the c i t i e s w i t h o u t p r i m a r y health  care",  he  also  declared,  "that  by  1980  o r g a n i z a t i o n should be r e s t r u c t u r e d so t h a t s i x t y p e r c e n t i t s regular budget was the provison  a l l o c a t e d to t e c h n i c a l cooperation,  of services to member s t a t e s . "  36  the of and  This meant that  the a d m i n i s t r a t i v e budgets of the r e g i o n a l o f f i c e s would be reduced with a corresponding reduction i n s t a f f . been w e l l  received  by  some members o f t h e  This had world  not  health  110  b u r e a c r a c y who  have f a i l e d t o implement t h i s program t o the  best  abilities.  of t h e i r  of  the  b e n e f i t s t h a t working f o r an i n t e r n a t i o n a l o r g a n i z a t i o n  can  provide.  They have grown too  fond  37  Objections  have a l s o been r a i s e d by  developed s t a t e s as the "Health  s e v e r a l of  the  f o r A l l Program" has brought  t h i s organization i n t o c o n f l i c t with the i n t e r e s t s of business and the l a r g e r m u l t i n a t i o n a l corporations of the w o r l d . WHO  has  1970s.  The  38  become i n c r e a s i n g l y a c t i v e i n t h i s area i n the I t s e n t i r e involvement  i n the  development  late of  a  marketing code f o r breast milk s u b s t i t u t e s r a i s e d great concern amongst the m u l t i n a t i o n a l c o r p o r a t i o n s .  The  pharmaceutical  i n d u s t r y f e a r s t h a t i t w i l l be the next t a r g e t o f WHO interference. statements  For  this  regarding  organization  the  has  substantial  pharmaceutical products are  frequently  drain  f o r developing  sponsored  of  made  resources  countries,  and  how  the drugs s u p p l i e d are, t o a g r e a t degree, inadequate f o r the needs of these countries. standardized  and  regulated  throughout the world. the tobacco firms. health r i s k and improve the  The WHO to  The WHO  I t has  ensure  a  fair distribution  has a l s o i n c u r r e d the wrath of  i n c r e a s i n g l y condemned smoking as a  i n i t i a t e d a worldwide campaign against  o v e r a l l general  forays of the Organization  l e v e l of health.  i t , to  These  recent  have brought i t i n t o c o n f l i c t  the more developed s t a t e s who multinationals.  has already proposed they be  with  r e p r e s e n t the i n t e r e s t s of the  The United States,  i n p a r t i c u l a r , has had  the  Ill  strongest r e a c t i o n to t h i s change i n the agenda of the WHO. was  It  the o n l y c o u n t r y t o v o t e a g a i n s t the M a r k e t i n g Code f o r  breast milk  s u b s t i t u t e s and has e s p e c i a l l y under the Reagan  administration  accused the WHO  M a r x i s t ideologues". the  organization  contribution;  o f c a t e r i n g t o " T h i r d World  I t has expressed i t s d i s p l e a s u r e w i t h by  increasingly  reducing  its  budget  to date i t has paid $10,000,000 of i t s assessed  $62,000,000 dues t h i s year (1987).  This a c t i o n has placed  the  o r g a n i z a t i o n i n a severe f i n a n c i a l c r i s i s and i s viewed as an attempt t o f o r c e the WHO compatible with U.S. CONCLUSIONS - WHY  t o r e t u r n t o p o s i t i o n s t h a t are more  business i n t e r e s t s .  THE  3 9  EVOLUTION ?  While t h i s c o n f l i c t w i t h the developed s t a t e s had r e f l e c t e d t o some degree i n the World H e a l t h  been  Organization's  G e n e r a l Assembly, i t has not i n f a c t permeated the top l e v e l of this  organization,  the  Executive  Board.  These i n d i v i d u a l s  remain committed t o the g o a l s of "Health f o r A l l by the Year 2000" Program.  T h i s i s l a r g e l y the r e s u l t o f the t e c h n i c a l  n a t u r e of the WHO. representatives  At the l e v e l o f the E x e c u t i v e are  physicians;  they  share  Board a l l a  common  p r o f e s s i o n a l bond, as medicine has c e r t a i n u n i v e r s a l princples. It  i s only  natural  for  these  i n d i v i d u a l s to  desire  an  improvement i n the health of a l l people, f o r t h i s i s what they were t r a i n e d t o p r o v i d e . improving  These p h y s i c i a n s are committed to  international public  organizational  ideology  of the  health WHO:  the  and  to  the  current  a t t a i n m e n t of  the  112  highest l e v e l of health f o r a l l ; the value of a preventative rather than a curative approach —  developing  i n t e r n a l health  structures, rather than responding t o emergencies —  they agree  t h a t t h e o r g a n i z a t i o n should be u n i v e r s a l i n membership and technical minimum. Board  i n scope, 40  with  political  i n t r u s i o n s kept  As w e l l , the i s s u e s d i s c u s s e d  are l a r g e l y t e c h n i c a l ,  directly  to a  by t h e E x e c u t i v e  relating  to health.  Symbolic d e c i s i o n s i n v o l v i n g East-West c o n f l i c t s a r e r a r e ; those statements occur i n the more p o l i t i c a l arena of the World Health  Assembly.  Most on the Executive  Board represent  their  country's n a t i o n a l health ministry, they are not concerned with the more p o l i t i c a l issues of state departments. Despite WHO  the high degree of t e c h n i c a l representation, the  has not been c o m p l e t e l y f r e e from t h e l a r g e r p o l i t i c a l  debates that have plagued the United Nations. Assembly has been s u b j e c t  t o t h e same p o l i t i c a l  ideology and p o l i t i c a l manoeuvring. forces at work occurred World Health Assembly. the  organization  operation. failure  forces of  The f i r s t example of such  s h o r t l y a f t e r the f i r s t session of the The Soviet bloc countries withdrew from  citing  In r e a l i t y ,  t o provide  The World Health  their  dissatisfaction  with i t s  they withdrew t o p r o t e s t t h e WHO's  supplies  as w e l l  as s e r v i c e s .  Other  i n c i d e n t s w i t h s t r o n g i d e o l o g i c a l overtones have o c c u r r e d i n t h i s organization,  a l t h o u g h f o r the most p a r t t h e c o n f l i c t  today tends t o be more North-South than East-West.  In the  past, p o l i t i c a l r e s o l u t i o n s i n c l u d e d condemning South A f r i c a  113  and  I s r a e l , not f o r health reasons, but because of States  are  not  willing  to  collaborate  ideology.  for  alturistic  reasons; they take a c t i o n t h a t b e n e f i t s t h e i r s e l f - i n t e r e s t . To d e c r e a s e the t h r e a t of d i s e a s e enterprises  and  travellers,  e r a d i c a t i o n programs.  to i n t e r n a t i o n a l business  developed  states  supported  They were also w i l l i n g to devote l i m i t e d  r e s o u r c e s t o d e v e l o p i n g c o u n t r i e s h e a l t h i n f r a s t r u c t u r e s , to encourage t h e i r c o o p e r a t i o n  i n o t h e r areas.  When i t comes t o  greater issues of p o l i t i c a l importance, however, states act to preserve  their  autonomy.  traditional  They act according  I t i s the  technical  concerns:  own  accord,  brought the  the  and  national  to t h e i r national i n t e r e s t .  e l i t e s that are responsible  e v o l u t i o n of the g o a l s of the WHO. their  power  f o r the  They have i n i t i a t e d ,  "Health For A l l Program", which  organization  into d i r e c t c o n f l i c t with  m u l t i n a t i o n a l firms and a few developed states.  on has  several  This evolution  i s beyond the boundary of the t r a d i t i o n a l a s p i r a t i o n s of t h i s i n t e r n a t i o n a l o r g a n i z a t i o n , but as w i t h o t h e r the WHO  had developed a dynamic of i t s own  bureaucracies,  and has e v o l v e d i n  ways t h a t c o u l d not be f o r s e e n by the o r i g i n a l s i g n a t o r i e s t o i t s charter.  Compliance has  organization.  I t was  Board t h a t  states  because of  a lack  r e a l i z e d by  failed of  ceased t o be a c o n c e r n of t h i s  to  will,  members of the  comply but  n e c e s s a r y r e s o u r c e s t o comply.  with  regulations,  because they As  Executive  such, the  lacked  not the  international  h e a l t h regime i s no l o n g e r concerned w i t h r e g u l a t i o n ; i t i s  114  concerned with helping to provide adequate health measures f o r every  citizen.  115  ENDNOTES - CHAPTER FOUR 1.  C. A. Pannenborg, A New I n t e r n a t i o n a l H e a l t h Order; An Inquiry i n t o the I n t e r n a t i o n a l Relations of Health, Alphen aan den R i j n : S i j t h o f f and Noordhoff, 1979), p. 286.  2.  Quoted i n " M a l a r i a : The Change i n S t r a t e g y " (Geneva: The Chronicle of the World Health Organization, V o l . 13, # 910., p. 342.  3.  N e v i l l e Goodman, I n t e r n a t i o n a l Health Organizations and T h e i r Work, (Baltimore: The Willams and Wilkins Co, 1971), p. 77.  4.  I b i d . , p. 78.  5.  D.M. L e i v e , I n t e r n a t i o n a l R e g u l a t o r y Regimes: Case Studies i n Health, Meterology, and Food. (Lexington, Ma.: L e x i n g t o n Books, D.C. Heath, 1976) p. 10.  6.  I b i d . , P- 142.  7.  I b i d . , P- 148.  8.  I b i d . , P- 141.  9.  I b i s . , P- 25.  10.  I b i d . , P- 31.  11.  F r a s e r Brockington, World H e a l t h , (Edinburgh: L i v i n g s t o n e , 1975), p. 155.  12.  Leive, P. 96.  13.  I b i d . , P- 78.  15.  I b i d . , P- 80.  16.  I b i d . , P- 84.  17.  I b i d . , P- 88.  18.  I b i d . , P- 94.  19.  I b i d . , P- 58.  20.  I b i d . , P- 64.  Churchill  116 21.  I b i d . , p. 96. I n d i a and S r i Lanka (then Ceylon) once e x t e n s i v e l y i n f e c t e d had passed i n t o the maintenance phase, only to experience some 2,000,000 cases during the years 1967-69.  22.  Goodman, p.  23.  I b i d . , p. 78.  24.  ibid.  25.  Interview with Dr. Maureen Law, Deputy M i n i s t e r of Health and W e l f a r e , and Head, Canada's D e l e g a t i o n t o the World Health Assembly, Past Chair of the Executive Board of the WHO. Ottawa, Ont., J u l y 2, 1987.  26.  Leive, p. 31.  27.  Harold Jacobson, "WHO: Medicine, Regionalism, and Managed P o l i t i c s " i n The Autonomy of Influence: Decision Making i n I n t e r n a t i o n a l Organizations, edited by Robert Cox (New Haven: Yale U n i v e r s i t y Press, 1974) p. 178.  28.  CA. Pannenbory, A New I n t e r n a t i o n a l Health Order, (Alphen aan den R i j n : S i j t h o f f and Noordhoff, 1979), pp. 203-204.  29.  "WHO and NIEO" Annual Report of the D i r e c t o r General f o r 1975. C h r o n i c l e , v o l . 30,#6 June 1976, p. 215.  30.  I b i d . , p.  31.  Global Strategy f o r Health f o r A l l by (Geneva: WHO, 1982), p. 11.  32.  I b i d . , p. 12.  33.  "WHO a t the C r o s s r o a d s " 219.  34.  Contained i n the Preamble to the C o n s t i t u t i o n .  35.  Pannenbourg, p. 23.  36.  "WHO  37.  I am indebted to Dr. Nancy Morrisson of the Department of Sociology, UBC, f o r p o i n t i n g out t h i s f a c t to me.  38.  Yves Beigeder, " I n t e r n a t i o n a l H e a l t h and T r a n s m a n t i o n a l Business: C o n f l i c t or Cooperation" i n I n t e r n a t i o n a l Review of A d m i n i s t r a t i v e Sciences", March 1983.  252.  218. the  Year  2000.  C h r o n i c l e , Vol. 31, #6, 1977, p.  at the Crossroads" pp. 209,  217.  F a c t s a s c e r t a i n e d i n i n t e r v i e w w i t h Mr. Bruce M i l l e r , Department Of E x t e r n a l A f f a i r s , Canada, U n i t e d N a t i o n s D i r e c t o r a t e . Ottawa, Ont., June 30, 1987. Jackobson, p. 203.  118  CONCLUSION THE DEVELOPMENT AND EVOLUTION OF INTERNATIONAL HEALTH COLLABORATION The  aim  progression  of t h i s  thesis  has been  t o document t h e  of i n t e r n a t i o n a l health c o l l a b o r a t i o n , t o account  f o r both the success,  and the obstacles i t has encountered.  As  i t has been demonstrated cooperation throughout the development of the i n t e r n a t i o n a l health regime has undergone an evolution, i n terms of i t s degree and i n t e n s i t y . THE EVOLUTION OF THE HEALTH REGIME As  collaboration i n international health  i n t e r n a t i o n a l health regime i t s e l f evolved.  grew t h e  I t surpassed i t s  i n i t i a l purpose as a r e g u l a t o r y regime t o become a t e c h n i c a l assistance-oriented organization. only  concerned w i t h  Through t h e y e a r s expanded  the r e g u l a t i o n of quarantine  t h e focus  to include  restrictions  O r i g i n a l l y the regime was  much  of t h i s more  measures.  regime has g r a d u a l l y  than  the r e g u l a t i o n of  on i n t e r n a t i o n a l t r a v e l . In i t s second  century  t h i s regime has become concerned with a r r e s t i n g the spread of disease;  i t undertook a program of e r a d i c a t i o n against c e r t a i n  p e s t i l e n t diseases. success,  countries,  their  total  but demonstrated t o the o r g a n i z a t i o n t h e need t o  develop t h e h e a l t h  endemic.  These programs d i d not meet w i t h  i n f r a s t r u c t u r e i n t h e l e s s e r developed  where the m a j o r i t y  of epidemic  diseases  were  A s s i s t i n g states i n providing primary health care to  nationals  i s now  t h e focus  of i n s t r u c t i o n a l  health  119  collaboration,  representing a long progression  from i t s former  concern with regulation. T h i s e v o l u t i o n has o c c u r r e d  w i t h i n t h e dynamics o f the  growth i n i n t e r n a t i o n a l health regimes. conferences  were  ad hoc a f f a i r s ,  threatening  epidemic  c o n f e r e n c e s had o n l y  suddenly  one item  At f i r s t , the sanitary convened  presented  epidemic.  i t was  The  a temporary  r e s t r i c t i o n s , o r the  o f measures t o combat t h e spread  Over t i m e  when a  itself.  on t h e agenda,  s o l u t i o n t o e i t h e r impending q u a r a n t i n e establishment  only  realized  that  of a raging  the lack of a  permanent body t o apply and i n t e r p r e t sanitary regulations d i d not encourage compliance.  Thus, t h e c r e a t i o n o f s u c c e s s i v e  international  health  responsibility  and j u r i s d i c t i o n  Membership international composition  organizations,  each  than  with  greater  t h e one b e f o r e i t .  i n these  institutions  also  health  regime went from  expanded;  the  a l a r g e l y European  t o global membership under the United  Nations.  The agendas o f t h e s e regimes have g r e a t l y expanded from erecting disease,  measures  to protect  against  a single,  t o considering several p e s t i l e n t diseases,  directing  research  i n t o a myriad  specific as w e l l as  of i n t e r n a t i o n a l health  concerns and coordinating i n t e r n a t i o n a l t e c h n i c a l commissions. Where t h e i n t e r n a t i o n a l h e a l t h regime once c o n s i s t e d o f prohibitive guidelines  regulations, and r e q u e s t s .  i t i s now  composed  The emphasis  o f suggested  o f t h e regime has  evolved from the prevention and defense of the developed states  120  to assistance and has  advice  f o r T h i r d World nations.  Regulation  i n c r e a s i n g l y ceased to be an a c t i v i t y of the health regime.  Under  the  requests  World  Health  are the rule.  Organization  recommendations  Compliance continues  to be  and  problematic  i n the i n t e r n a t i o n a l health regime; i t does not appear to have significantly  improved or d e t e r i o r a t e d under any  formation  of  the regime. Within  the  regime i t s e l f t h e r e has  change i n l e a d e r s h i p .  been a fundamental  Where the developed European n a t i o n s  i n i t i a t e d the Sanitary Conferences to protect themselves from the  importations  of  exotic  disease  from  l e s s e r developed  c o u n t r i e s , i t i s now the i s s u e s and concerns o f the T h i r d World t h a t dominate the w o r l d h e a l t h agenda.  These c o u n t r i e s  are  l a r g e l y unconcerned with ensuring the reduction i n impediments to trade and  m u l t i n a t i o n a l corporations' a c t i v i t i e s .  they are anxious t o ensure the development of t h e i r  Instead, health  i n f r a s t r u c t u r e s and t o g a i n an equal d i s t r i b u t i o n of h e a l t h resources,  i n terms of medical personnel,  and  pharmaceuticals.  Under the World Health Organization, the health regime has,  in  f a c t , e v o l v e d from p r o t e c t i n g the i n t e r e s t s o f i n t e r n a t i o n a l business  from damaging q u a r a n t i n e  posing a d i r e c t threat to  r e s t r i c t i o n s , to at times  the i n t e r e s t s of large m u l t i n a t i o n a l  corporations. In s p i t e of the g r e a t scope of t h i s e v o l u t i o n i t has been f r e e of c o n f l i c t t h e s i s has  or p o l i t i c a l  suggested t h e r e  opposition.  As  not this  have been s e v e r a l o b s t a c l e s  to  121  achieving  complete cooperation i n i n t e r n a t i o n a l health.  OBSTACLES TO INTERNATIONAL HEALTH COLLABORATION States  were,  at  first,  reluctant  c o l l a b o r a t i v e ventures to c o n t r o l the  spread of disease.  were quite content to follow t h e i r own u n t i l the  to p a r t i c i p a t e  in  They  p o l i c i e s of quarantine  s u b s t a n t i a l growth i n i n t e r n a t i o n a l trade and t r a v e l  f o r c e d them t o a c c e p t the n e c e s s i t y of j o i n t a c t i o n t o remove the b a r r i e r s t o t r a d e i n d i v i d u a l a c t i o n had c r e a t e d . states' r e a l i z a t i o n of the  necessity  of c o l l a b o r a t i v e  they were unable to reach agreement on the appropriate to  be  taken.  transmission,  A  scientific  debate  over  with states supporting d i f f e r e n t p o s i t i o n s ,  regarding  the  and the origns of these diseases was  views regarding the  from a g r e e i n g t o a r e g u l a t o r y  After  these  discoveries  international  were  collaborative  made  measures of  i n progress,  according to t h e i r  these diseases  states  action,  means  q u a r a n t i n e . A l a c k of s c i e n t i f i c  e t i o l o g i e s of  Despite  was  knowledge to  prevent  code f o r f o r t y y e a r s . in  the  late  1800s  e f f o r t s became much e a s i e r  to  instigate. Gradually  the need f o r i n t e r n a t i o n a l health  organizations  became apparent, to administer the sanitary conferences and r e v i s e the codes t h a t had efforts. states  to  r e s u l t e d from t h e s e c o l l a b o r a t i v e  Through t h e i r experiences i n the s a n i t a r y conferences had  learned  t h a t the  coordination  of r e s e a r c h  i n t e r n a t i o n a l l e v e l made economic sense, as a l l s t a t e s then b e n e f i t  on  an  could  from s c i e n t i f i c advances i n epidemiology without  122  d u p l i c a t i n g t h e process.  T h i s encouraged s t a t e s t o support  f u r t h e r c o l l a b o r a t i o n i n health issues. Other o b s t a c l e s t o  c o l l a b o r a t i o n were t o be p o s e d by  i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n s , which had a tendency t o develop t h e i r own i n s t i t u t i o n a l l o y a l t i e s . b e n e f i t s t h a t came  Due i n part t o the  from p a r t i c i p a t i o n i n t h i s  organization,  i n c l u d i n g the d e l i g h t s of l i v i n g i n a foreign, cosmopolitan city  such as P a r i s , t h e employees o f t h e OIHP developed a  l o y a l t y t o the aims and process of t h e i r organization.  Similar  to other employees i n a large bureaucracy, they were r e s i s t a n t to changes i n the organization that could e i t h e r threaten t h e i r position  or the i n s t i t u t i o n  s t a f f e d by v e t e r a n s  itself.  The OIHP was l a r g e l y  o f t h e e a r l y S a n i t a r y Conferences.  They  brought t o t h i s new o r g a n i z a t i o n t h e i r b e l i e f s i n t h e aims o f i n t e r n a t i o n a l h e a l t h c o l l a b o r a t i o n formed, i n p a r t , by these conferences.  These members were, t h e r e f o r e , not keen on t h e  new developments i n i n t e r n a t i o n a l p u b l i c health care i n terms of t e c h n i c a l a s s i s t a n c e t h a t t h e H e a l t h O r g a n i z a t i o n o f t h e League i n t e n d e d t o p r o v i d e . the  goals  of the early  Instead, they wanted t o c o n t i n u e sanitary  regime  to lessen the  impediments t o i n t e r n a t i o n a l trade and t r a v e l while  preventing  the spread of epidemic disease from l e s s developed countries. This  same p r o c e s s  was repeated  when t h e Pan American  Sanitary Bureau was to be absorbed i n t o the newly formed World Health  Organization.  i n s t i t u t i o n objected  A g a i n t h e members o f t h e s m a l l e r  to a loss i n their t r a d i t i o n a l  influence  123  and  power.  The  WHO  i s presently  experiencing  a similar  s i t u a t i o n of bureaucratic r e v o l t i n i t s implementation of the Health For A l l Program.  The aims of t h i s program, t o return to  the p r o v i s i o n of p r i m a r y h e a l t h c a r e by i n d i v i d u a l s t a t e s , threatens the large appendage of bureaucratic e l i t e s that accumulated i n the regional o f f i c e s of the The  last  three  examples  have  WHO.  a l l show o b s t a c l e s  to the  f u r t h e r i n g of i n t e r n a t i o n a l health c o l l a b o r a t i o n caused not by states,  b u t by  the i n t e r n a t i o n a l h e a l t h  organziations  themselves. A f t e r the F i r s t World War i t was generally believed that international auspices  health  work should  be c a r r i e d out under the  of t h e f i r s t m u l t i l a t e r a l  i n s t i t u t i o n designed t o  f o s t e r i n t e r n a t i o n a l g o o d w i l l , the League o f Nations.  Also,  t h e r e was an obvious need f o r an i n t e r n a t i o n a l h e a l t h body t o respond t o t h e s e r i o u s typhus and i n f l u e n z a e p i d e m i c s t h a t struck Europe a f t e r the war. the  international level  crisis. technical  Only a coordination of e f f o r t at  could  adequately  respond  to  this  The League had a mandate t o f u r t h e r i n t e r n a t i o n a l cooperation,  increasingly  involved  and i t s h e a l t h i n conducting  organization technical  became  studies  on  diseases that had a strong i n t e r n a t i o n a l presence. W h i l e t h e League was political  t o be a t e c h n i c a l  issues d i d o c c a s i o n a l l y a r i s e .  institution  The French expressed  some r e l u c t a n c e t o cooperate i n i t i a l l y w i t h c o u n t r i e s i t had r e c e n t l y fought  against.  The U n i t e d S t a t e s was a l s o wary o f  124  the S o v i e t Union's p a r t i c i p a t i o n i n the h e a l t h o r g a n i z a t i o n ' s activities;  i t was  not to enjoy diplomatic r e l a t i o n s with t h i s  country u n t i l a f t e r the Second World War.  To a c e r t a i n extent,  however, p o l i t i c a l d i s p u t e s were subsumed by the t e c h n i c a l g o a l s of the o r g a n i z a t i o n . participated  in  the  Russia,  Health  Germany, and  Organization  of  Japan a l l  the  League's  activities,  even though they d i d not at the time belong to the  League.  Ultimately,  however,  the  i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n was the League i t s e l f ,  success  of  this  t i e d t o the success  of  and as one's c r e d i b i l i t y f a l t e r e d , so d i d  the other's. Throughout the duration of the League, epidemic were  largely  Consecutive  under  sanitary  c o n s o l i d a t e d i n 1903 1912  and  1926.  quarantine  had  the  had  developed  been  nations.  established  and  w i t h amending c o n f e r e n c e s o c c u r r i n g i n abolished  time  scientific  w e l l developed i n the treatment and  containment  welfare  and  the  most p a r t ,  By  trade  ensured  f o r the  obstruction  of these diseases,  facilities  in  minimal  international  social  codes  T h e s e had,  and  knowledge was  control  diseases  travel.  this  as the Western states had  systems  that  for their citizens.  provided  w e l l established  public  health  While the o r i g i n a l  of the health regime had been f u l f i l l e d ,  to  care  objectives  collaborative efforts  i n i n t e r n a t i o n a l health were to proceed. Adequate sanitary and health provisions were s t i l l needed i n the underdeveloped n a t i o n s , and w i t h the f o r m a t i o n  of the  125  World H e a l t h O r g a n i z a t i o n , stated  goal  of  the  p r o v i d i n g f o r t h e s e needs became a  international health  regime.  This  is  demonstrated by the comprehensive d e f i n i t i o n of health that the C o n s t i t u t i o n of t h i s organization contains. sought to eradicate disease, international  traveller  At f i r s t ,  WHO  as i t s t i l l posed a danger to the  and  the  multinational  s e t t i n g up a factory i n a disease plagued country. discovered,  the  corporation I t was  soon  however, that e r a d i c a t i o n programs were l i k e l y to  encounter f a i l u r e because of the lack of medical and s a n i t a t i o n s e r v i c e s i n the very countries where the diseases were rampant. As w e l l , for  there were often c u l t u r a l d i f f e r e n c e s that accounted  the f a i l u r e of e r a d i c a t i o n programs.  once an outbreak was capital cities. neither  the  Complacency developed  under c o n t r o l and had receded from the  Many of t h e s e underdeveloped c o u n t r i e s  resources,  nor  the  will  to  carry  out  a  had full  e r a d i c a t i o n program. Other d i f f i c u l t i e s i n c o n t r o l l i n g the spread of d i s e a s e were s t a t e s ' f a i l u r e t o comply w i t h Sanitary or Health Codes.  the r e g u l a t i o n s of  Noncompliance was  the  extensive f o r many  reasons: a lack of resources to e i t h e r c o l l e c t data or transmit it,  fears  of  financial  losses  to  tourism,  as  well  as  r e p r e c u s s i o n s t o t r a d e caused by the i m p o s i t i o n o f e x c e s s i v e measures by other countries as a r e s u l t of t h e i r reporting the existence of a p e s t i l e n t disease.  Admitting  an outbreak of a  p e s t i l e n t d i s e a s e c a r r i e d the mark of a T h i r d World e n t a i l i n g a l o s s of p r e s t i g e f o r the n o t i f y i n g country.  country,  126  The  t e c h n i c a l e l i t e s of the WHO  soon r e a l i z e d that  little  c o u l d be done t o stop t h e s e a c t s of noncompliance except the p r o v i s i o n of t e c h n i c a l a i d and health resources  to counter the  diseases that motivated these actions themselves. WHO  As such, the  has abandoned r e g u l a t o r y a c t i v i t i e s because they were no  longer  compatible  cooperation. health  1  What was  s e r v i c e s on  become the new  with  an  its original needed was  the  goals,  technical  p r o v i s i o n of  i n d i v i d u a l country  basis.  basic  This  has  g u i d i n g p r i n c i p l e of the i n t e r n a t i o n a l h e a l t h  regime. The  explanation  f o r t h i s development l i e s i n the growing  acceptance amongst Western developed s t a t e s t h a t h e a l t h care was  a fundamental s o c i a l r i g h t .  As n a t i o n s t a t e s began t o  r e a l i z e t h a t they had a r e s p o n s i b i l i t y f o r the h e a l t h care of t h e i r i n d i v i d u a l c i t i z e n s they t r a n s f e r r e d t h i s b e l i e f to  the  international  it  gradually  level.  became an  Within  accepted  the  s o c i e t y of n a t i o n s  norm t h a t  the  more advanced  nations had a r e s p o n s i b i l i t y to improve the health of the l e s s fortunate and l e s s developed nations. accepted unanimously.  2  This p r i n c i p l e was  not  Most of the developed countries were not  w i l l i n g t o p r o v i d e the l e s s developed c o u n t r i e s w i t h the a i d needed  to  develop  their  health  infrastructures.  m u l t i n a t i o n a l firms have also grown suspicious of the WHO  Large as i t  t a k e s an i n c r e a s i n g l y c r i t i c a l stance towards some of t h e i r a c t i v i t i e s r e g a r d i n g the T h i r d World.  They are supported by  some of the developed states, e s p e c i a l l y the United States,  who  127  do n o t l i k e t h e t u r n i n d i r e c t i o n t h e WHO d e c o l o n i z a t i o n i n t h e 1960s World  countries  has taken s i n c e a  added a l a r g e number o f T h i r d  to the organization.  The U n i t e d  States'  growing displeasure with t h i s s i t u a t i o n has been expressed by a s u b s t a n t i a l reduction i n i t s budget contribution, causing the WHO  great d i f f i c u l t i e s  carrying  i n meeting i t s r e s p o n s i b i l i t i e s and  out i t s programs.  T h i s a c t i o n poses t h e l a r g e s t  obstacle to the future of i n t e r n a t i o n a l h e a l t h c o l l a b o r a t i o n for the WHO today. The e l i t e of the organization, and a few Western nations, are  sympathetic  nations  to the p l i g h t  include:  Netherlands.  3  Sweden,  o f t h e T h i r d World. Denmark,  and t h e  I t i s the t e c h n i c a l e l i t e s , however, who c o n t r o l  the agenda o f t h i s o r g a n i z a t i o n . political  Norway,  These  As a r e s u l t o f an e a r l i e r  compromise, e s t a b l i s h e d a t t h e League o f Nations,  members of the World Health Organization's  Executive Board are  elected on the basis of t h e i r t e c h n i c a l expertise and as t h e i r own persons t o represent the aims of the organization, not the p o s i t i o n s of t h e i r respective governments. allowed  This s i t u a t i o n has  these i n d i v i d u a l s t o guide the organization along the  o r i g i n a l path suggested by i t s progressive c o n s t i t u t i o n . Collaboration  i n the World Health  Organization  has  undergone an i n c r e d i b l e evolution from the o r i g i n a l aims of the s a n i t a r y regulations and the health regime, designed t o ensure the p r e v e n t i o n trade.  o f t h e spread o f d i s e a s e and the f r e e flow o f  Today the organization i s more concerned with improving  128  the general l e v e l of health care f o r a l l of i t s members. The obstacles t o i n t e r n a t i o n a l health c o l l a b o r a t i o n were the  result  o f many f a c t o r s :  collaborate; etiologies  insufficient  a lack of p o l i t i c a l scientific  of the p e s t i l e n t diseases;  knowledge  w i l l to of the  the tendency of  i n t e r n a t i o n a l h e a l t h o r g a n i z a t i o n s t o develop a b u r e a u c r a t i c mentality; a lack of economic and health care resources, and an unwillingness  to provide  repercussions  to trade  these resources;  and t o u r i s m ;  f e a r o f economic  and, t h e i n t r u s i o n o f  p o l i t i c a l c o n f l i c t s i n t o the health arena. INTERNATIONAL RELATIONS THEORY AND INTERNATIONAL HEALTH COLLABORATION The  developments  i n international  c o l l a b o r a t i o n have not occurred beginning, area  health  without opposition.  From the  s t a t e s have been r e l u c t a n t t o c o l l a b o r a t e i n t h e  of i n t e r n a t i o n a l health.  collaboration  had a l r e a d y  been  Even when t h e precedent o f well  established,  and the  b e n e f i t s r e a l i z e d , s t a t e s c o n t i n u e d t o o b j e c t o r v i o l a t e the terms  o f i n t e r n a t i o n a l agreements.  The reasons  f o r the  development of i n t e r n a t i o n a l health c o l l a b o r a t i o n , and f o r the r e l u c t a n c e o f some s t a t e s t o p a r t i c i p a t e , as w e l l as f o r the e v o l u t i o n t h a t t h i s i n t e r n a t i o n a l regime has undergone, can best  be  understood  R e l a t i o n s Theory.  with  the assistance  of I n t e r n a t i o n a l  Of t h e f o u r themes o u t l i n e d i n t h e f i r s t  chapter, two b e s t e x p l a i n t h e i n s t i g a t i o n and development o f i n t e r n a t i o n a l c o l l a b o r a t i o n , while the other two are u s e f u l i n  129 explaining  the  obstacles  p a r t i c i p a t e i n these  and  reluctance  of  states  to  ventures.  REALISM Realism  and  Neo-realism  are  theories that  concern  themselves w i t h the power of the n a t i o n s t a t e , e i t h e r w i t h i n the  i n t e r n a t i o n a l system or i n comparison t o o t h e r s t a t e s .  C l a s s i c a l r e a l i s m has l i t t l e t o say on the p o s s i b i l i t i e s of collaborative prevention.  efforts  I t i s not  of  s t a t e s i n the  area  of  g e n e r a l l y an i s s u e o f s u r v i v a l or a  f a c t o r of power f o r a s t a t e .  T h i s e x p l a i n s the  disinterest  states o r i g i n a l l y displayed towards health cooperation international level;  i t was  at the  not an issue of p r i o r i t y f o r them.  In response t o a t h r e a t e n i n g concerned and  disease  e p i d e m i c s t a t e s would become  take p r e v e n t i v e measures, but as t h i s  crisis  receded, the focus o f s t a t e s r e t u r n e d t o more c r u c i a l i s s u e s , such as the attainment Neo-realism  and preservation of power.  i s more u s e f u l i n explaining the development  of i n t e r n a t i o n a l h e a l t h c o l l a b o r a t i o n .  Neo-realism  modifies  c l a s s i c a l r e a l i s m , and c o n s i d e r s the o v e r a l l w e l f a r e of the s t a t e t o be as important i t s power.  The  i n g u i d i n g i t s a c t i o n s as p r e s e r v i n g  state, f o r n e o - r e a l i s t s , acts p r i m a r i l y i n i t s  s e l f - i n t e r e s t , t o p r o t e c t i t s s e c u r i t y o r i t s s t a n d i n g i n the i n t e r n a t i o n a l system.  The  s e c u r i t y of a nation state depends  upon more than i t s amount of power o r m i l i t a r y  capability.  Other f a c t o r s , such as economic w e l f a r e , s e c u r i n g access to strategic  resources,  and  ensuring  the  well-being  of i t s  130 c i t i z e n s become i n v o l v e d .  Preserving  the  s a n c t i t y of  the  nation state, i t s c u l t u r a l autonomy, or national sovereignty  is  also important, as these f a c t o r s define what i s a nation state. A state w i l l take a c t i o n against any development that threatens i t s s e c u r i t y , be measure.  It  international increasing cannot  i t a s p r e a d i n g e p i d e m i c or a h a r m f u l t r a d e  will  cooperate  with  other  arrangements when i t i s t o  some a s p e c t of i t s s e c u r i t y .  come  sovereignty  at  great  cost  to  a  or economic w e l f a r e .  state  or  in  i t s benefit,  in  This  states  collaboration  i n terms  of  its  I f i t does, a s t a t e w i l l  r e l u c t a n t t o p a r t i c i p a t e i n the c o l l a b o r a t i v e venture.  be  If a  state's i n t e r e s t s change, or an i n t e r n a t i o n a l agreement i t has committed i t s e l f t o i s no l o n g e r p r o f i t a b l e or b e n e f i c i a l , a state w i l l not h e s i t a t e to withdraw from c o l l a b o r a t i v e e f f o r t s . Within  the  framework  of  international  c o l l a b o r a t i o n , neo-realism best explains the i n i t i a l of s t a t e s t o c o l l a b o r a t e , s e l f - i n t e r e s t to do  so —  until to  i t became c l e a r l y  health reluctance in their  ensure trade l i b e r a l i z a t i o n  to c o n t r o l the spread of disease.  and  Even a f t e r they had r e a l i z e d  the v a l u e of c o l l a b o r a t i o n , s t a t e s would v i o l a t e or f a i l  to  comply w i t h h e a l t h r e g u l a t i o n s they had once agreed t o , or be r e t i c i e n t about further c o l l a b o r a t i v e e f f o r t s . Throughout the e a r l y sanitary conferences there was a reluctance  always  on the part of states to r a t i f y a convention that  would i n some way  l i m i t t h e i r actions without ensuring that  t h e i r i n t e r e s t s were protected.  Despite the general acceptance  131 of the i d e a t o h o l d an i n t e r n a t i o n a l s a n i t a r y conference, i t was t o t a k e a l m o s t twenty y e a r s b e f o r e European s t a t e s would even agree to meet.  The French had suggested such a conference  as e a r l y as 1834, y e t the f i r s t c o n f e r e n c e was not h e l d u n t i l 1951.  Certain  c o u n t r i e s were a m b i v a l e n t  sanitary conference; A u s t r i a was c o n f e r e n c e f o r which i t saw  t o the i d e a of a  r e l u c t a n t to p a r t i c i p a t e i n a  no r e a l need.  As a l a n d l o c k e d  country removed from the source of epidemics, i t was u n a f f e c t e d by t h e i r scourge.  B r i t a i n , too, l a t e r expressed a  great d i s d a i n f o r the e n t i r e conference system. had  t o be  coaxed  relatively  I t frequently  t o a t t e n d c o n f e r e n c e s w i t h promises  i s s u e s t h a t were v i t a l  t o i t s economic i n t e r e s t s ,  that  such  as  imposing l e n g t h i e r quarantine on ships passing through the Suez Canal, would not be discussed. States  were  concerned  agreement that was  with  forging  an  international  favourable to t h e i r n a t i o n a l i n t e r e s t .  They  were u n w i l l i n g to compromise on any convention that would even p a r t i a l l y harm t h i s i n t e r e s t . fact  that  i t took  This i s best demonstrated  f o r t y - o n e y e a r s b e f o r e t h e r e was  success i n these c o l l a b o r a t i v e ventures; Seventh  i t was  I n t e r n a t i o n a l S a n i t a r y Conference  l i m i t e d c o n v e n t i o n was  i n the to  be  not u n t i l the  i n Venice that a  s i g n e d r e g a r d i n g the measures t o be  taken f o r ships destined f o r the Mecca pilgrimages. A f t e r t h i s f i r s t s u c c e s s i t was years  before  a  t o take the p a r t i c i p a n t s a f u r t h e r ten  comprehensive  convention  on  a l l relevant  diseases and quarantines would be signed by the p a r t i c i p a t i n g  132 nations.  Even though c o l l a b o r a t i v e e f f o r t s repeatedly  met  with  f a i l u r e , states continued to return to the conference fourm, as they r e a l i z e d t h a t an i n t e r n a t i o n a l s o l u t i o n was solve  the  imposition against  common p r o b l e m s of  stringent  trade.  of  and  epidemic  damaging  needed t o  disease  and  quarantine  the  measures  Yet they were u n w i l l i n g t o compromise on a  s o l u t i o n that would not be i n t h e i r best i n t e r e s t . The  issues that  most concerned s t a t e s  Conference centered upon two autonomy of a s t a t e , and  items.  The f i r s t was  the second was  t r a d i n g i n t e r e s t s were not harmed. sovereignty  arose  conferences.  several  i n the  times  the national  ensuring  The  Each t i m e a measure was  that t h e i r  i s s u e of  i n the  Sanitary  political  history  of  proposed t h a t  the  would  r e s t r i c t the t r a d i t i o n a l j u r i s d i c t i o n of a state there would be a large outcry. International  The best example of t h i s occurred Sanitary  Conference when the  at the  United  Fifth  States'  r e q u e s t f o r p e r m i s s i o n t o be g r a n t e d t o t h e i r n a t i o n a l s  to  inspect  an  a l l ships  bound  f o r US  ports  was  greeted with  emphatic n e g a t i v e by o t h e r d e l e g a t e s because i t would be a v i o l a t i o n of t h e i r s o v e r e i g n t y .  The European c o u n t r i e s  felt  t h a t such an a c t i o n q u e s t i o n e d the c a p a b i l i t y and honour of t h e i r medical  facilities.  Prestige and that  are  status are aspects of i n t e r n a t i o n a l p o l i t i c s  c l o s e l y l i n k e d to national autonomy and  M a t t e r s of p r e s t i g e c h a r a c t e r i s t i c t o one  are  usually  nation.  issues  that  For i n s t a n c e ,  sovereignty.  are unique at the  or  sanitary  133  conferences  a l l e f f o r t s t o p l a c e r e s t r i c t i o n s on the Mecca  pilgrimages  were r e j e c t e d by  Turkey as  an  affront  r e l i g i o n and a v i o l a t i o n of i t s c u l t u r a l autonomy and as  a nation state.  In f a c t ,  Turkey d i d not  to i t s standing  sign a  single  S a n i t a r y Conference i n the n i n e t e e n t h c e n t u r y because almost all  of them sought t o impose s p e c i a l measures a g a i n s t  the  Muslim pilgrimages. P r o t e c t i n g the constant concern  i n t e r e s t s of i n t e r n a t i o n a l t r a d e was  a  i n the e a r l y development of the i n t e r n a t i o n a l  health regime.  States with a large degree of trade t r a v e r s i n g  the Suez Canal  had  q u i t e d i f f e r e n t g o a l s t o p r o t e c t a t the  sanitary conferences  than those with l e s s e r t r a d i n g i n t e r e s t s .  C o u n t r i e s w i t h s i g n i f i c a n t t r a d e were the most s u p p o r t i v e of the r e g u l a t i v e a s p e c t s of t h i s regime, w h i l e those c l o s e r t o the apparent source o f the epidemics  f e l t p s y c h o l o g i c a l l y at  g r e a t e r r i s k and p r e f e r r e d the s e c u r i t y o f s t r i c t measures.  Each grouping  quarantine  of states advocated t h e i r respective  views on t h i s matter because these measures supported what best f o r t h e i r n a t i o n a l i n t e r e s t and security. factor  in a  quarantine was  state's p o s i t i o n  long  the  determining  imposition  of  l e s s a r e f l e c t i o n of t h e i r b e l i e f i n t h i s method  of prevention than i t was state's  regarding  The  was  term  a r e f l e c t i o n of what would be i n the  interest.  This point  explains  Britain's  s h i f t i n g o p i n i o n s r e g a r d i n g the source of the c h o l e r a v i b r o . Britain  initially  accepted  the general consensus expressed  at  the F o u r t h Conference t h a t c h o l e r a o r i g i n a t e d i n I n d i a , y e t  134 denied  this  Conference.  same  fact  twenty  years  later  at  the  Sixth  As t i m e passed B r i t a i n grew more r e l u c t a n t t o  p a r t i c i p a t e i n t h e s e conferences.  T h i s i s e v i d e n c e d by t h e i r  r e j e c t i o n of a Permanent Commission on E p i d e m i c s where they expressed  a  "want  of  faith  i n t e r n a t i o n a l s a n i t a r y work".  i n the  value  of  co-operative  This, no doubt, had a great deal  t o do w i t h the f a c t t h a t they were always i n the advocating  the  s u b s t i t u t i o n of m e d i c a l  minority,  inspections  for  quarantine. Even a f t e r a s u c c e s s f u l i n t e r n a t i o n a l h e a l t h regime had been formed, s t a t e s c o n t i n u e d  t o o b s t r u c t c o l l a b o r a t i o n by  r e f u s i n g t o comply w i t h measures t h a t c o n f l i c t e d w i t h perceived s e l f - i n t e r e s t .  T h i s was  their  the case w i t h f a i l u r e s t o  n o t i f y the outbreaks of reportable disease and compliance with the  regulations  measures. question  States  concerning  the  imposition  of  excessive  found themselves i n a p o s i t i o n where the  became whether  to  comply  with  the  notification  requirements of the regime and r i s k the imposition of damaging trade measures, or to avoid these measures by not reporting the breakout of a n o t i f i a b l e disease.  As there was  an established  h i s t o r y of states imposing excessive measures upon l e a r n i n g of an outbreak, many states f a i l e d to n o t i f y the WHO, to r i s k economic losses to trade or tourism i m p o s i t i o n of excessive unabated  even today  and  measures. has  not  wishing  as a r e s u l t of the  This p r a c t i c e  continues  r e c e n t l y been a t t r a c t i n g  new  f o l l o w e r s as a r e s u l t of h y s t e r i a r e g a r d i n g the spread of the  135 AIDS pandemic. States have been g r e a t l y security  their  and s e l f - i n t e r e s t throughout t h e f o r m a t i o n o f t h e  i n t e r n a t i o n a l health regime. or prevented c o l l a b o r a t i o n in  concerned with p r o t e c t i n g  a state's  collaboration  best  Although t h i s has often  disrupted  when actions have not proven t o be  interest,  i t has a l s o  encouraged  f o r t h e same reason, when i t s e r v e s a state's  s e l f - i n t e r e s t and enhances i t s p o s i t i o n i n t h e i n t e r n a t i o n a l system. A health regulatory from  t h e spread  growing  trade  regime was formed t o p r o t e c t  of epidemic disease interests  as much  states  and t o s h e l t e r  as p o s s i b l e  i n c r e a s i n g l y damaging e f f e c t s of quarantine.  their  from t h e  Yet, as the above  examples demonstrate, a Neo-Realist perspective  i s perhaps best  at e x p l a i n i n g t h e f a i l u r e o f s t a t e s t o c o l l a b o r a t e as opposed to  providing  collaborative relations  an e x p l a n a t i o n efforts.  a r e more u s e f u l  f o r the i n s t i g a t i o n of  Other t h e o r i e s  of i n t e r n a t i o n a l  i n accounting  f o r the p o s i t i v e  developments i n the i n t e r n a t i o n a l health regime. LIBERALISM L i b e r a l theories in  t h e work o f Edward  increases of  Morse  and R i c h a r d  Cooper,  predict  i n i n t e r n a t i o n a l c o l l a b o r a t i o n w i l l occur as a r e s u l t  the modernization  industrialization. and  of i n t e r n a t i o n a l r e l a t i o n s , as expressed  process  initiated  by t h e f o r c e s  of  The world has become more interdependent,  t h i s has caused  a major  change  i n t h e nature  of the  136 i n t e r n a t i o n a l system.  In order to enjoy the b e n e f i t s of strong  economic r e l a t i o n s h i p s , s t a t e s must be certain  amounts of  achieving  national  independence and  t h e i r economic objectives.  the t r a d i t i o n a l r e a l i s t g o a l s  w i l l i n g to give autonomy  up in  States have moved beyond  of power and  s e c u r i t y t o more  s u b t l e ones such as the expansion of economic w e l l - b e i n g the p r o v i s i o n of a more equitable d i s t r i b u t i o n of wealth.  and As a  r e s u l t of m o d e r n i z a t i o n the norms of i n t e r n a t i o n a l b e h a v i o u r have been enlarged. nations  I t i s becoming the o b l i g a t i o n of wealthy  t o r e d i s t r i b u t e some of the  poorer nations.  world's w e a l t h t o  4  In o r d e r t o improve economic w e l f a r e , willing  the  t o reduce b a r r i e r s t o the  s t a t e s have been  f r e e f l o w of t r a d e .  In  explaining the development of the i n t e r n a t i o n a l health regime, l i b e r a l i s m accounts f o r states' gradual acceptance of the need for  the  coordination  quarantine measures.  of  regulations  States  will  and  the  reduction  of  surrender the autonomy they  once guarded to ensure the p r o v i s i o n of economic gains to t h e i r countries.  T h i s development  was  the major impetus behind  i n t e r n a t i o n a l health c o l l a b o r a t i o n . Before states had was  merely  an  development of  extensive  inconvenience efficient  became a s e r i o u s  and  t r a d i n g i n t e r e s t s , quarantine to  travellers.  means of transportation,  c o s t l y impediment t o t r a d e .  With  the  quarantine As t h e i r  t r a d i n g i n t e r e s t s grew, states gradually came to r e a l i z e t h i s p o i n t and s a n i t a r y codes were f i n a l l y concluded t o a l l e v i a t e  137 t h i s f i n a n c i a l l y harmful s i t u a t i o n . Britain,  as t h e l a r g e s t  trading  nation at that  provided the strongest opposition to quarantine.  time,  Throughout  the conferences, i t s p o s i t i o n became more b e l l i g e r e n t . countries  came t o a c c e p t  t r a d i n g i n t e r e s t s grew.  Britain's  position  Other  as t h e i r  own  Those w i t h a l a r g e degree o f t r a d e ,  mainly Northern European states and northern France, sided with B r i t a i n much e a r l i e r than those c l o s e r t o t h e s o u r c e s o f the d i s e a s e ' s spread, Mecca. With  t h e a d o p t i o n o f s u c c e s s f u l s a n i t a r y codes  i n the  1890s, t h e p r i n c i p l e s o f t h e h e a l t h regime were e s t a b l i s h e d . They were strongly suggested by l i b e r a l i s m , that the spread of disease  s h o u l d be c h e c k e d  by p r o c e d u r e s  which  are not  excessively harmful t o the progress of i n t e r n a t i o n a l trade. As i n t e r n a t i o n a l health development progressed, improving the economic p o t e n t i a l o f a s t a t e a l s o became a p a r t o f t h i s regime.  Developed states were strong supporters of e r a d i c a t i o n  programs, not o n l y because  they were t o r i d t h e w o r l d o f a  p e s t i l e n t disease, thereby ensuring that these countries need never have t o guard a g a i n s t them, but a l s o because they made the w o r l d s a f e f o r i n t e r n a t i o n a l b u s i n e s s and t r a v e l .  Less  developed c o u n t r i e s were not a b l e t o i n s t i g a t e development programs u n t i l a s u f f i c i e n t amount of t h e i r population was free from disease.  Also, epidemic diseases i n these countries posed  a s e r i o u s economic d r a i n i n terms o f t h e l o s s o f a p o t e n t i a l workforce.  138 Liberalism  also  explains  regime i n the twentieth  the  century.  evolution  of the  While the former p r i n c i p l e s  have been r e t a i n e d , an a d d i t i o n has  r e c e n t l y been made t h a t  t h e r e should be an e q u i t a b l e d i s t r i b u t i o n of h e a l t h throughout resources ones.  the  world.  This  entails  welfare  a t r a n s f e r of  from the developed s t a t e s t o the  The WHO  health  health  lesser-developed  has attempted t o implement t h i s new  norm w i t h  programs o f t e c h n i c a l c o o p e r a t i o n .  Although t h e s e measures  have  a l l states,  not  been  well  received  by  n e v e r t h e l e s s , p a r t o f the m o d e r n i z a t i o n p r o c e s s exists in this  are,  which Morse  describes.  Conflict  cooperation  because the changes t o the i n t e r n a t i o n a l system  t h a t m o d e r n i z a t i o n has  area  they  of i n t e r n a t i o n a l  wrought are not y e t complete.  The  s i g n i f i c a n t changes t h a t have a l r e a d y o c c u r r e d as a r e s u l t of t h i s process  i n c l u d e the l o s s of power by the European s t a t e s  and an i n c r e a s e i n the t o t a l number o f s t a t e s .  Both of t h e s e  changes are r e f l e c t e d i n the World Health Organization and provide explanations this  f o r the development of new  organization that d i f f e r s i g n i f i c a n t l y  goals,  before  modernization  had  today,  programs i n  from i t s previous  changed  the  fundamental  s t r u c t u r e of the i n t e r n a t i o n a l system. FUNCTIONALISM As  a theory  i n i n t e r n a t i o n a l r e l a t i o n s , Functionalism  is  most u s e f u l i n explaining the advances i n health c o l l a b o r a t i o n and the e v o l u t i o n w i t h i n the h e a l t h regime.  T h i s theory i s  based on the e s s e n t i a l premise that as a r e s u l t of the growing  139 complexity  of the world,  states w i l l  no  l o n g e r be a b l e t o  provide adequately f o r t h e i r c i t i z e n s the b e n e f i t s they have i n the  past.  They  will  be  forced to  turn to  international  t e c h n i c a l organizations to provide s o c i a l welfare goals and to ensure that t e c h n i c a l issues that cross n a t i o n a l j u r i s d i c t i o n s will  be  administered  successfully.  These  international  o r g a n i z a t i o n s are t o be s t a f f e d by t e c h n i c a l e l i t e s who e x p e r t s i n the area of c o l l a b o r a t i o n .  They w i l l , because of  t h e i r t e c h n i c a l t r a i n i n g , be a b l e t o s e p a r a t e the  political  i s s u e s from the t e c h n i c a l s o l u t i o n s t h a t are r e q u i r e d . result,  are  As a  c o l l a b o r a t i v e v e n t u r e s between s t a t e s i n t e c h n i c a l  areas w i l l  l e a d t o g r e a t e r l e v e l s of c o o p e r a t i o n as s t a t e s  r e a l i z e the success to be gained from these j o i n t actions. P r e v e n t i n g the spread of d i s e a s e by d e v e l o p i n g standard h e a l t h r e g u l a t o r y codes i s an area t h a t c r o s s e s the n a t i o n a l jurisdiction achieved.  of s t a t e s and needs t e c h n i c a l e x p e r t i s e t o be With the growing amount o f t r a d e and t r a v e l t h a t  o c c u r r e d i n the n i n e t e e n t h century, the spread o f c o n t a g i o u s diseases became more extensive throughout the world, i n Europe.  The S a n i t a r y Conferences  especially  were an attempt a t the  i n t e r n a t i o n a l l e v e l to resolve t h i s problem and to ensure the f r e e f l o w of t r a d e .  S u c c e s s f u l c o o p e r a t i o n was  not t o occur  u n t i l s c i e n t i f i c d i s c o v e r i e s had been made i s o l a t i n g the causes of epidemic disease.  A f t e r t h i s discovery, states r e a l i z e d the  value and necessity of s c i e n t i f i c this  area  and  and p o l i t i c a l cooperation i n  institutionalized  i t i n the  formation  of  140 i n t e r n a t i o n a l health organizations with t e c h n i c a l goals. o r g a n i z a t i o n s began t o develop a l i f e of t h e i r own, and  have l e d t o  an  e v o l u t i o n i n the  health  These  however,  regime and  an  increase i n c o l l a b o r a t i v e e f f o r t s . As health  f o r the n a t u r e of t e c h n i c a l c o o p e r a t i o n regime has  adoption  itself,  shown some p o s i t i v e developments.  the The  of the c o n t r a c t i n g out procedure demonstrates  the  degree t o which the former p o l i t i c a l a s p e c t s of the s a n i t a r y r e g u l a t i o n s have been reduced t o mere t e c h n i c a l i s s u e s , not requiring  the  implicit  approval  of  dominated by the medical profession: a country's country's  states.  The  WHO  is  v i r t u a l l y every member of  d e l e g a t i o n i s a p h y s i c i a n , and  represents  their  m i n i s t r y of health, rather than the more p o l i t i c a l l y  motivated departments that are responsible f o r f o r e i g n p o l i c y . The occurred  successes  of the  i n t e r n a t i o n a l h e a l t h regime have  as a r e s u l t of t e c h n i c a l cooperation.  The e r a d i c a t i o n  of smallpox came about l a r g e l y because of the h i g h l y t e c h n i c a l n a t u r e of i t s s o l u t i o n . What was  needed was  A v a c c i n e was  an e f f i c i e n t  way  already i n existence. to i n o c u l a t e a large  enough p e r c e n t o f the p o p u l a t i o n i n an endemic area t o stop the transmission under the  of t h i s disease.  auspices  of the  With i n t e r n a t i o n a l cooperation  WHO,  the  vaccine  i n j e c t i o n were s u c c e s s f u l l y modified and  and  method  of  smallpox has become a  disease of the past. The WHO  i s motivated to  f u l f i l the i d e a l s of i t s Charter  because physicians share the ambition  of preventing unnecessary  141 sickness and disease, a b e l i e f which they bring with them when they  represent  Despite  their  the f a c t  country  that  at the i n t e r n a t i o n a l  government o f f i c i a l s  without  s p e c i a l i z e d t r a i n i n g may not share t h e i r i d e a l s , s p e c i a l i s t s have been remarkably successful  level. their  these  health  i n a few instances  of e n s u r i n g c o l l a b o r a t i o n on i s s u e s which a r e not i n many o f t h e i r country's p e r c e i v e d s e l f - i n t e r e s t . this  A good example o f  i s t h e WHO/UNICEF code on M a r k e t i n g  Substitutes,  Milk  which was regarded by t h e f o r e i g n m i n i s t r i e s o f  some states as financial  of Breast  adversely a f f e c t i n g i n t e r n a t i o n a l trade and the  positions  of multinational  pharmaceutical  corporations. Yet  despite  collaboration,  the successes  political  issues  in international  still  a r i s e t o i n t e r f e r e with  the more t e c h n i c a l and c o l l a b o r a t i v e aspects of health  work.  This  health  i s e s p e c i a l l y true  international  i n t h e World H e a l t h  Assembly, where s t a t e s a r e r e p r e s e n t e d by t h e more p o l i t i c a l factions  o f governments.  A s p i l l o v e r of the c o l l a b o r a t i v e  s p i r i t from the medical aspect of the organization  t o the more  p o l i t i c a l area i s not yet evident. FINAL COMMENTS - PROGNOSIS FOR THE FUTURE OF INTERNATIONAL HEALTH COLLABORATION The is  evolution  the r e s u l t  that has occurred within  of the s p e c i a l  characteristics  international health collaboration. states  have c o l l a b o r a t e d  other,  more p o l i t i c a l ,  the health  regime  inherent i n  H e a l t h i s an area where  t o a much g r e a t e r degree than i n  areas of i n t e r n a t i o n a l r e l a t i o n s .  As  142  h e a l t h c a r e became an accepted s o c i a l r i g h t i n the developed nations  of the world, t h i s p r i n c i p l e was  international level. benefits  t r a n s f e r r e d t o the  A l l s t a t e s were e n t i t l e d t o enjoy the  of good h e a l t h ,  and  the  developed n a t i o n s  had  an  o b l i g a t i o n to a s s i s t the l e s s developed ones i n achieving t h i s goal.  While t h i s i d e a l has been subject to the same p o l i t i c a l  forces  as o t h e r s o c i a l w e l f a r e i s s u e s a t the  international  l e v e l , such as human r i g h t s , health c o l l a b o r a t i o n has been more successful  because of  the  M e d i c a l p e r s o n n e l at the t h e i r colleagues  nature of  i t s technical  elites.  i n t e r n a t i o n a l l e v e l , working w i t h  a t the n a t i o n a l l e v e l , have managed t o push  c o l l a b o r a t i o n i n t h i s regime f a r t h e r than nation states would l i k e , and the repercussions be  felt  by  the  to t h i s a c t i o n are now  organization,  as  funds  and  beginning to support  are  withdrawn. Collaboration  has  increased  within  the  International  H e a l t h Regime, and each of the f o u r t h e o r i e s of I n t e r n a t i o n a l Relations  sheds l i g h t on a d i f f e r e n t f a c t o r t o e x p l a i n t h i s  development.  Realism  and  Neo-Realism  best  opposition to c o l l a b o r a t i o n , while L i b e r a l i s m and  explains  the  Functionalism  suggest occasions when c o l l a b o r a t i o n w i l l be successful. As area,  f o r the  f u t u r e of i n t e r n a t i o n a l c o o p e r a t i o n  i t appears  inevitable.  that  increased  collaboration  in this will  be  As AIDS i n c r e a s i n g l y becomes a g l o b a l problem, the  developed s t a t e s of the West w i l l be f a c e d f o r the f i r s t time t h i s century with a threatening epidemic disease f o r which they  143  have no cure or treatment.  This s i t u a t i o n has not caused such  a p a n i c i n the l e s s developed s t a t e s as AIDS f o r them i s y e t another d i s e a s e s t r i k i n g t h e i r p o p u l a t i o n .  With i t s sudden  appearance i n an a l m o s t e p i d e m i c form, developed s t a t e s are e r e c t i n g b a r r i e r s i n an attempt t o stop i t s spread. beginning  to pose great d i f f i c u l t i e s  This i s  for international t r a f f i c  and commerce.  As w e l l , developing  n o t i f y the WHO  of the existence of t h i s disease, l e s t i t cause  repercusions excessive already  states have been f e a r f u l to  to t h e i r t o u r i s t i n d u s t r i e s .  measures r e g a r d i n g  been r e p o r t e d .  S e v e r a l cases  i n t e r n a t i o n a l t r a v e l l e r s have  These i n c i d e n t s r e c a l l  p e r i o d when the i n t e r n a t i o n a l h e a l t h regime was created.  of  an  earlier  just  being  As AIDS threatens to b r i n g about s i m i l a r b a r r i e r s as  quarantine,  with equally damaging r e s u l t s , states no doubt w i l l  enter i n t o c o l l a b o r a t i v e arrangements to ensure the free flow of i n t e r n a t i o n a l t r a f f i c . regime w i l l  be  A l l the p r i n c i p l e s of the h e a l t h  strengthened,  and  the  lessons  learned  e a r l i e r health c o l l a b o r a t i o n w i l l be applied once again.  from  144  ENDOTES - CONCLUSION  1.  Interview with Dr. Jean L a r i v i e r e , Senior Medical Advisor, I n t e r n a t i o n a l H e a l t h A f f a i r s D i r e c t o r a t e , Department o f Health and Welfare, Canada.  2.  C. A. Pannenborg, A New International Health Order, (Alphen aan den R i j n l S i j t h o f f and Noordhoff, 1979) p. 23.  3.  Harold Jackobson, "WHO: Medicine, Regionalism, and Managed P o l t i t i c s " i n The Autonomy of Influence. (New Haven: Yale U n i v e r s i t y Press, 1974), p. 214.  4.  Edward Morse, Modernization and the Transformation of I n t e r n a t i o n a l Relations, (New York: The Free Press, 1976), p. 45.  145  BIBLIOGRAPHY A l l e n , C.E. "World H e a l t h and World P o l i t i c s " . INTERNATIONAL ORGANIZATION 4. (1950). p. 27-43. Ascher, C h a r l e s S. "Current Problems i n t h e World H e a l t h O r g a n i z a t i o n ' s Program". INTERNATIONAL ORGANIZATION 6. (1952). p. 27-50. B a s c h , P a u l F. INTERNATI0NAL_HEALTH. U n i v e r s i t y Press, 1978).  (New  York:  Oxford  Beigbeder, Yves. " I n t e r n a t i o n a l H e a l t h and T r a n s n a t i o n a l Business: C o n f l i c t or Cooperation" INTERNATIONAL REVIEW OF ADMINISTRATION SERVICES". 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"The Influence of I n t e r n a t i o n a l P o l i t i c s on the A c t i v i t i e s of N o n - P o l i t i c a l S p e c i a l i z e d Agencies—A Case Study," POLITICAL STUDIES. V o l . 13 (June, 1965): 247-51. Riggs, Robert E. "The Bank, The IMF and the WHO". JOURNAL OF CONFLICT RESOLUTION. V o l . 24. (1980): 329-357. S i k k i n k , K a t h r y n . "Codes o f C o n d u c t F o r T r a n s n a t i o n a l Corporations: The Case o f t h e WHO/UNICEF Code". INTERNATIONAL ORGANIZATION. (1986): 815-840. Silverman, M i l t o n , P h i l i p R. L e e and M i a Lydecker. P r e s c r i p t i o n s For Death: The Drugging of the T h i r d World. (Berkeley: U n i v e r s i t y of C a l i f o r n i a Press, 1982). Stein, Arthur. "Coodorniation and Collaboration: Regimes i n an A n a r c h i c World". I n t e r n a t i o n a l Regimes, ed. Stephen Krasner. (Ithaca: C o r n e l l U n i v e r s i t y Press, 1983).  148  "Towards New I n t e r n a t i o n a l Sanitary Regulations" WHO CHRONICLE Vol 3. Waltz, Kenneth. Theory of I n t e r n a t i o n a l R e l a t i o n s . (New York: Random House, 1979). "WHO  and the New I n t e r n a t i o n a l Economic Order" WHO V o l . 30.  "WHO a t the Crossroads".  CHRONICLE  WHO CHRONICLE. V o l . 13  WHO. BASIC DOCUMENTS. (Geneva: World Health Organization, 1983). WHO. The F i r s t Ten Years of the World (Geneva: WHO, 1958). WHO.  The Second Ten Years of the World 1958-1967. (Geneva: WHO, 1982).  WHO.  Global Strategy For Health (Geneva: WHO, 1982).  WHO. S p e c i a l Program on Aids, 1987.  Health Health  Organization Organization  F o r A l l By t h e Year 2000  149  INTERVIEWS  Dr.  Maureen  Law  - Deputy M i n i s t e r o f H e a l t h and Welfare, Ottawa. Past P r e s i d e n t o f t h e E x e c u t i v e Board of the World Health Organization. Head, Canadian D e l e g a t i o n t o the World Health Organization.  Dr. Jacques L a r i v i e r e  Mr.  Barney M i l l e r  Prof.  Yves  - S e n i o r M e d i c a l A d v i s o r t o t h e World H e a l t h O r g a n i z a t i o n , Department o f Health and Welfare, Ottawa.  - United Nations Directorate, Department of External A f f a i r s , Ottawa.  Beigbeder  - V i s i t i n g P r o f e s s o r , Department of P o l i t i c a l S c i e n c e , UBC - Summer 1987. Past A d m i n i s t r a t i v e O f f i c i a l of the World Health Organization.  Prof. Nancy Morrisson - Department of Sociology, UBC  

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