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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 J e n n i f e r E l a i n e J o l l y B.A.(Hons.), 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 i n THE FACULTY OF GRADUATE STUDIES Department of P o l i t i c a l Science We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA October 1987 t£} J e n n i f e r E l a i n e J o l l y , 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of P o l i t i c a l Science The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date October 14, 1987. i i ABSTRACT The goal of t h i s thesis i s to document and explain the e v o l u t i o n and development of i n t e r n a t i o n a l h e a l t h collaboration. U t i l i z i n g international relations theory, the i n i t i a l development of the health regulatory regime i s traced through the early sanitary conferences. The establishment of i n t e r n a t i o n a l health organizations i s then documented, along with the transformation this entailed in international health collaboration. The resulting effect the institutionalization of the i n t e r n a t i o n a l health regime had upon i n t e r n a t i o n a l health collaboration i s f i n a l l y presented. I t i s determined t h a t s t a t e s i n i t i a l i n t e r e s t i n 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 grew out of a concern for reducing the impediments to international trade and commerce that quarantine measures imposed. States were, at f i r s t , r e l u c t a n t to c o l l a b o r a t e , but as s c i e n t i f i c knowledge increased, i n t e r n a t i o n a l cooperation i n t h i s area expanded. Realizing the benefits of joint technical cooperation, states formed 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 s . The s p e c i a l c h a r a c t e r i s t i c s of i n t e r n a t i o n a l health under the guiding influence of medical s p e c i a l i s t s were to cause an evolution within this regime. Collaboration i n t h i s area has greatly increased. The primary concern of the international health regime i s no longer the containment of p e s t i l e n t diseases without s i g n i f i c a n t i i i i n terference to i n t e r n a t i o n a l commerce. This regime i s now concerned with improving the l e v e l of health care to a l l states, regardless of the e f f e c t s t h i s might have on the interests of the developed states. Technical cooperation and aid to developing countries i s now the c e n t r a l focus of the World Health Organization. This evolution has not occurred without some degree of c o n f l i c t , however, as i t i s the developing states and the medical e l i t e s of the organization have forced the evolution of the previous norms of this regime. The developing states have a c l e a r i n t e r e s t i n securing assistance in developing their health infrastructures, and the e l i t i e s of the WHO are committed by nature of their s c i e n t i f i c training to work towards this ideal. The developed states are not i n favour of t h i s change as i t threatens t h e i r i n t e r e s t s and power within this regime. Although i t i n i t i a l l y appeared that 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 to secure as an improvement i n health would be to every state's benefit, t h i s has not always been the case. International r e l a t i o n s theory i s u t i l i z e d i n t h i s t h e s i s to explain the o r i g i n s , the obstacles, and the evolution that has occurred within this regime. 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 - Theoretical Framework - The Development of International Health Collaboration. Realism. Neo-Realism or Structural Realism. Liberalism. Functionalism. Endnotes - Chapter One. Chapter Two - The Early 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 Third 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 Early Conferences. Endnotes - Chapter Two. Chapter Three- The Institutionalization of the International Health Regime — The Establishment of International Health Organizations. Organization International d'Hygine Publicrue. Twelfth International Sanitary Conference. The Effects of World War One on International Health Collaboration. D i f f i c u l t i e s in International Health Collaboration - Institutional Loyalty. The Health Organization of the League of Nations. Thirteenth Internatinal Sanitary Conference. The Effects of The Second World War on International Health Collaboration. Post War Health Collaboration - The U N Relief and Rehabilitation 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 Eradication. 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 ? I l l Endnotes - Chapter Four. 115 Conclusion - The Development and Evolution of International Health Collaboration. 118 The Evolution of the Health Regime. 118 Obstacles to International Health Collaboration. 121 International Relations Theory and International Health Collaboration. 128 Realism. 129 Liberalism. 135 Functionalism. 138 Final Comments - Prognosis for the Future of International Health Collaboration. 141 Endnotes - Conclusion. 144 Bibliography Interviews 145 149 v i ACKNOWLEDGEMENTS As I r e f l e c t back over the past four months I r e a l i z e that the completion of t h i s t h e s i s would not have been possible without the assistance of several i n d i v i d u a l s . As t h i s w i l l probably be the only chance I w i l l ever get to do t h i s sort of th i n g , I would l i k e to take t h i s o p p o r t u n i t y to thank everybody, even i f i t w i l l prove to be a b i t sentimental at times. F i r s t of a l l , my appreciation i s extended to a l l those i n d i v i d u a l s who granted me an interview for the research of this thesis. Their names are too numerous to mention here, but can be located in the Bibliography. I wish to especially thank Dr. Maureen Law, Deputy M i n i s t e r of Health and Welfare for taking time out of her busy schedule to inform me of current developments within the WHO. I also have to acknowledge the constant support that my mother and family have extended to me during t h i s sometimes trying endevour. Friends in Vancouver also must be mentioned for alternately encouraging, or distracting, me from this task. Shannon, Charles, Michelle, Francis, Martin (who was endlessly explaining the differences between realism and neo-realism) and Juanita, I w i l l miss you a l l . Gratitude must also be expressed to Nancy Mina who, in the midst of my upheaval from one end of the c i t y to another, found me an o f f i c e i n which the l a t t e r part of t h i s t h e s i s was completed. My friends, Michelle, Don, and Lynn also deserve mention and thanks for providing me with a place to sleep at times during the last troubled months of this odyessy. F i n a l l y , I wish to thank the members of my committe for t h e i r h e l p f u l suggestions and c r i t i c i s m s . This t h e s i s would not have been completed within the deadline without the sometimes fri g h t e n i n g counsel of Professor Mark Zacher who orig i n a l l y proposed this topic. My deep appreciation i s also extended to my thesis advisor, Professor Don Munton, who not only edited and provided suggestions that s i g n i f i c a n t l y improved this thesis, but also enabled me to complete i t with some degree of my sanity intact. 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, pestilent diseases were thought to be the punishment of the Gods. I t was not u n t i l i t was r e a l i z e d t h a t epidemic d i s e a s e s were transmitted through human contact that health care and disease prevention became an i n t e r n a t i o n a l issue, as these were problems that crossed national boundaries and j u r i s d i c t i o n . Originally, the method most commonly employed to contend with the spread of epidemic disease was quarantine, with the earl i e s t example occurring in 532 AD when the Emperor Justine of Constantinople i n s t i t u t e d i t to combat the great Plague epidemic. 1 Widespread use of quarantine did not occur, however, u n t i l l a t e r i n the f i f t e e n t h century, when the maritime city-state of Venice instituted a quarantine where persons or goods were to be isolated, in a restricted location, for a s p e c i f i c period of time, believed to be equal to the incubation period for the disease. This was to be the model, being quickly i n s t i t u t e d by other European nations. Soon after, b i l l s of health were inaugarated, although they did not come into general use u n t i l 1665.2 Issued by the country of destination's consul, they were designed to prove that as of the l a s t port of c a l l , the suspected ship was free from disease, thus freeing a ship from a lengthy quarantine period. Quarantine regulations varied from state to state and 2 b i l l s of h e a l t h were f r e q u e n t l y s u b j e c t to b r i b e r y and corruption. 3 These incidents caused great inconvience to passengers and considerable financial loss to trading nations. F i n a n c i a l repercussions were soon to become acute with the f i r s t effects of the Industrial Revolution beginning to appear in the ninteenth century. Trade had r a p i d l y increased, f a c i l i t a t e d by the development of the steamship 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 pressure from these f i n a n c i a l losses would f i n a l l y to force s t a t e s to convene meetings i n an e f f o r t to s o l v e the obstruction that quarantines and b i l l s of health were posing to trade at the international level. I n i t i a l l y , various proposals were made with regards to the coordination of quarantine measures along the Mediterranean. Although an i n t e r n a t i o n a l conference was f i r s t proposed by France in 1834, i t was not u n t i l 1851 that the European nations f i n a l l y agreed to assemble to discuss this international issue. Another f a c t o r that prompted t h i s conference was the Cholera epidemic that ravaged Europe between 1828 and 1831, causing states to adopt s t r i c t e r and thus, more economically c o s t l y quarantine measures. At the same time s e v e r a l other i n t e r n a t i o n a l conferences were occurring to discuss other highly technical issues that crossed national boundaries, such as the ones that led to the creation of the International Postal and Telegraphic Union. It was, however, the financial pressures that quarantine 3 measures were placing upon growing trade that f i n a l l y provided the impetus that resulted in the f i r s t international action to address t h i s common problem. As well, the increase i n the numbers of people attending the Mecca pilgrimage had greatly c o n t r i b u t e d to the spread of c h o l e r a to Europe and by immigration to the Americas, when i t had previously been re l a t i v e l y contained in India and the East. 4 Countries weighed their particiation in such a conference against t h e i r national i n t e r e s t . Those with the greatest amount of trade, s u f f e r i n g the most from quarantine, were consequently the most i n favour of the r e g u l a t i o n and l i m i t a t i o n of these damaging measures. European states also wanted to protect t h e i r populations from these ravaging d i s e a s e s . There was, however, a d i s t i n c t g e o g r a p h i c a l determination to those countries in favour of greatly l i m i t i n g the use of quarantine and those that considered i t v i t a l that these measures remained i n place. The Southern countries on the Mediterreanean, the I t a l i a n c i t y - s t a t e s , A u s tria and Southern France, were cl o s e r to the source of 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 to geography, were less affected by the cholera epidemic and, had i n general, greater f i n a n c i a l i n t e r e s t s i n trade, were anxious for the removal of a l l unecessary impediments to trade. Quarantine measures were very much a European device to p r o t e c t the developed or " c i v i l i z e d " c o u n t r i e s from 4 contamination by the "barbarous" and underdeveloped nations. Gradually, and as a result of increased s c i e n t i f i c and medical knowledge regarding the etiologies of these epidemic diseases, i t was r e a l i z e d that 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 also financially costly. As knowledge of how to combat these epidemic diseases increased, i t encouraged international collaboration and the creation of international health organizations. As a result of international collaboration in this area, a h e a l t h r e g u l a t o r y regime was e v e n t u a l l y e s t a b l i s h e d to coordinate the various quarantine measures and b i l l s of health. A regime may be defined simply as a set of p r i n c i p l e s , norms, rules and decision making procedures around which actor expectations converge i n a given issue area. 5 I t should be pointed out that regimes r e f e r to voluntary c o l l a b o r a t i v e ventures undertaken by independent nation states. As the international system remains anarchical, with no supreme power, regimes have no power to enforce their codes or regulations. A state i s then free to violate international regulatory codes; the only motivation for a state's compliance with a regulatory regime's provisions i s to gain some item that i t cannot secure independently. In the case health the regulatory regime preceeded the establishment of an i n t e r n a t i o n a l health organization. When the Seventh International Sanitary Conference resulted i n a 5 successful convention i n 1893, t h i s regime came into being. Its principles were: the regulation of international trade and t r a v e l with regards to the prevention of epidemic diseases, while ensuring a minimum of interference to these commercial a c t i v i t i e s . The health regime was to become more f i r m l y grounded with the addition of several more Sanitary Conventions over the next ten years, culminating i n 1903 i n a single unified version. Cooparation in this regime was soon to evolve beyond mere r e g u l a t i o n , however. An i n t e r n a t i o n a l body, l ' O f f i c e International d'Hygiene Publique, was formed to coordinate and administer the e x i s t i n g i n t e r n a t i o n a l health codes. This agency was very much a European organization, although the functions that i t performed gradually grew u n t i l they were global in scope. With the advent of the League of Nations i n 1919 and the growth of international cooperation after the Second World War, the responsibilities of international health organizations grew tremendously. The international system i t s e l f had also grown to include those states beyond the borders of Europe and North America; i t now encompased many of the less developed states, whose numbers were to increase greatly i n the period of decolonization. This expansion in the number of states and the general destruction that occurred as a result of the two great wars was to lead to an increasing role for international health organizations such as the International Red Cross, the League 6 of Nations Health Organization, and eventually the United Nations and the World Health Organization. At the n a t i o n a l l e v e l s t a t e s began to take g r e a t e r r e s p o n s i b i l i t y f o r the h e a l t h and w e l l being of t h e i r i n d i v i d u a l c i t i z e n s , and t h i s p r i n c i p l e was g r a d u a l l y transfered to the international level. It eventually became a norm in international society that health care was a right for each c i t i z e n , and furthermore, that i t was the duty of more advanced nations to help those nations that were less developed or not as well endowed i n health resources. The most concrete expression of t h i s sentiment occurs i n the Charter of the World Health Organization, where i t s stated objective i s declared to be "the highest attainment by a l l peoples of the highest possible level of health" 6. This i s in addition to the previous norms of the regime, which were established by the developed states and imposed on their colonies. As a result of d e c o l o n i z a t i o n , these T h i r d World n a t i o n s have been s u c c e s s f u l l y challenging the norms of the previous health regime, which existed for the developed countries' benefit. The World Health Organization has encorporated this new norm of primary health care involving a transfer of health resources in the new global health strategy, Health For A l l by the Year  2000. This develoment has not occurred, however, without some resistence on the part of both the developed nations and the international organization i t s e l f . Ultimately this thesis w i l l seek to examine and assess the 7 evolution within the health regime; how cooperation i t s e l f evolved i n t h i s area. In so doing, i t w i l l be necessary to f i r s t examine, the creation of the health regulatory regime i t s e l f , and i t s t r a n s i t i o n from the Sanitary Conferences to today's World Health Organization. Then, the evolution that has occurred within this regime w i l l be outlined as well as the important factors that have shaped this development. Finally the obstacles that have existed and continue to e x i s t to f u l l cooperation in international health w i l l be explored making use of several theories of international relations. The f i r s t chapter w i l l lay the theoretical groundwork for the evolution of the health regime. I t w i l l o u t l i n e four theories of international relations, and show their relevance in explaining not only the development of the i n t e r n a t i o n a l h e a l t h regime, but a l s o the o b s t a c l e s t h i s process has encountered. The second chapter w i l l d e t a i l the i n i t i a l developments of the international health regulatory regime in the establishment of- the sanitary regulations and codes. The third chapter traces the further developments in international health, from the establishment of the League of Nations to the creation of the World Health Organization. The fourth chapter i s concerned with presenting the evolution that has occurred w i t h i n the h e a l t h regime and w i t h i n the World Health Organization. The conclusion w i l l interpret these developments and u t i l i z i n g the applicable theories of internation relations explain the reasons behind t h i s evolution. Ultimately, the 8 obstacles to f u l l international collaboration in this area w i l l be assessed, along with the implications they have for future international action in this area. 9 ENDNOTES - INTRODUCTION 1. Neville Goodman, International Health Organizations and  Their Work, (Baltimore: Williams and Wilkins Co., 1971), p. 29. 2. Robert Berkov, The World Health Organization: A Study in Decentralized International Administration, (Geneva: L i b r a i r i e E. Droz, 1957), p. 36. 3. Goodman, p. 35. 4. Ibid., p. 38. 5. Stephen Krasner, "Introduction" in International Regimes, (Ithaca: Cornell University Press, 1983), p. 1. 6. A r t i c l e I, The C o n s t i t u t i o n of the World Health Organization. 10 CHAPTER ONE THEORETICAL FRAMEWORK - THE DEVELOPMENT OF INTERNATIONAL HEALTH COLLABORATION From the perspective of most i n t e r n a t i o n a l r e l a t i o n s theorists the international transmission of disease i s an area where one 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 to 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 nations face to a degree and the control of i t s spread cannot be achieved through the actions of one state alone. As well, i t i s believed that health i s a r e l a t i v e l y uncontentious issue amongst states; an area of "low" p o l i t i c s , not generally thought of as involving the security or economic well-being of a state. When the development of the i n t e r n a t i o n a l health regime i s examined, however, one finds that collaboration did not occur as r e a d i l y as some t h e o r i s t s of i n t e r n a t i o n a l r e l a t i o n s would have predicted. International health issues have inc r e a s i n g l y impinged upon issues of "high" p o l i t i c s , affecting trade and even the security of a nation state. In examining the emergence of i n t e r n a t i o n a l h e a l t h cooperation, four 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 theory w i l l be compared to explain the i n t r a c a c i e s i n t h i s p a r t i c u l a r area of i n t e r n a t i o n a l a c t i o n . They are the following: Realism, Neo-Realsim or Modified S t r u c t u r a l Realism, Liberal i s m and Functionalism. Each one of these theories considers a specific factor to be the key explanatory 11 v a r i a b l e i n explaining why c o l l a b o r a t i o n has or has not occurred. Each explains a particular aspect of international health cooperation: the v a r i a b l e s relevant to the actors, the level of s c i e n t i f i c knowledge, and the state of international health at that time. Realism and Neo-Realism, i t w i l l be shown focus on the disadvantages of c o l l a b o r a t i o n , and explain why states are u n l i k e l y to collaborate, or v i o l a t e the terms of collaborative efforts. Functionalism and Libleralism are, on the other hand, more o p t i m i s t i c i n t h e i r expectations for 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 ; they pr e d i c t instances where international collaboration i s l i k e l y to occur. R e a l i s t s are concerned with the competion for power, s p e c i f i c a l l y the power of one nation state i n r e l a t i o n to a l l others, as expressed in both military and economic terms. M o d i f i e d S t r u c t u r a l R e a l i s t s propose t h a t s t a t e s ' paramount concern i s for their security or national autonomy, r a t h e r than t h e i r power r e l a t i v e to a l l other s t a t e s . Maintaining the national autonomy and economic well-being of the n a t i o n s t a t e i s the 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 l i t i e s of international collaboration. L i b e r a l s focus on states' concern with national wealth. They want to eliminate impediments to international commerce and to ensure the continued growth of national 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 to occur when impediments to i n t e r n a t i o n a l commerce are removed and when collaboration results in an increase in the wealth of nations. 12 F u n c t i o n a l i s m l o o k s to i n t e r n a t i o n a l t e c h n i c a l organizations to gradually overlay p o l i t i c a l d i v i s i o n s with common tasks. In this manner, war w i l l become both impratical and uneccessary. According to f u n c t i o n a l i s t s , meaningful collaboration w i l l occur with increased s c i e n t i f i c knowledge and the p a r t i c i p a t i o n of tec h n i c a l e l i t e s i n trans-national ventures. The above theories w i l l now be considered i n greater d e t a i l and t h e i r explanatory variables f o r i n t e r n a t i o n a l collaboration w i l l be further explained. REALISM The t h e o r e t i c a l construct of realism has, by and large, dominated the study of i n t e r n a t i o n a l r e l a t i o n s . From the writings of Thucidydes to Hans Morgenthau, c e r t a i n e s s e n t i a l concepts that form t h i s theory's t h e o r e t i c a l base can be seen consistently reappearing in the works of various r e a l i s t s . In general, r e a l i s t s believe human nature to be b a s i c a l l y e v i l ; human beings are concerned with acquiring as much power and influence as they possibly can for themselves. Human nature i s also thought to be constant: there i s l i t t l e chance or hope for improvement. And unlike l i b e r a l theories of international r e l a t i o n s , there i s no b e l i e f i n an underlying harmony of in t e r e s t s . As there i s no superior force imposing order upon states, the actions of human beings and nations w i l l naturally come into c o n f l i c t and lead to war as each state struggles to acquire power to protect i t s e l f or dominate others. The world 13 of states i s considered to be zero-sum: one state's loss i s another's gain i n terms of power and influence. This i s the t r a d i t i o n a l r e a l i s t viewpoint, best expressed by Hans Morgenthau in P o l i t i c s Among Nations. 1 The essential tenets of realism, can be summarized as the following: states act i n a r a t i o n a l manner and are the dominant actors i n the i n t e r n a t i o n a l system; force i s an e f f e c t i v e method of achieving foreign p o l i c y goals, and s e c u r i t y issues i n general p r e v a i l over economic and s o c i a l a f f a i r s i n the determination of a state's foreign p o l i c y . Within 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 slight degree and i s transitory. As such, transnational actors have l i t t l e or no power of their own.2 Recently realism has been modified to a certain extent so that i t more closely corresponds to international developments of the post world war two era. C l a s s i c a l realism considered power, expressed u l t i m a t e l y i n m i l i t a r y terms, to be the predominant goal of a l l states. 3 Modern r e a l i s t s , or neo-r e a l i s t s , believe that nation states are more concerned today with t h e i r security, taking into account more than j u s t military power. NEO-REALISM or STRUCTURAL REALISM Neo-realists or s t r u c t u r a l r e a l i s t s have added to the t r a d i t i o n a l r e a l i s t assumptions of human nature and the behaviour of nation states the concept of the i n t e r n a t i o n a l 14 system. This i s described as anarchical, where the main o r d e r i n g p r i n c i p l e i s s e l f - h e l p . A s t a t e ' s p r i m a r y r e s p o n s i b i l i t y must be to guarantee i t s own s u r v i v a l i n an anarchical system with other competing states. But as power i s not the only factor i n defining security, there are other goals that a state must seek to attain. Economic considerations can often be crucial to the national interest of a state. Some s t r u c t u r a l r e a l i s t s believe that states i n the i n t e r n a t i o n a l system are growing more interdependent; 4 that a state's national i n t e r e s t or s e c u r i t y depends to an extent on i t s i n t e r a c t i o n s with other states i n matters where i n d i v i d u a l action cannot lead to an optimal solution. T r a d i t i o n a l or c l a s s i c a l r e a l i s m p r e d i c t s l i t t l e collaboration between states; states are considered unlikely to collaborate and w i l l only enter into joint ventures when there i s no p o l i t i c a l cost i n terms of a loss of power or influence to them. S t r u c t u r a l realism, i n comparisson to c l a s s i c a l realism, i s p r i m a r i l y concerned about the s e c u r i t y of states within 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 to ensue when a state's s e c u r i t y would be enhanced to any degree without serious costs to another area. The world of nation-states i s not seen as being zero-sum; states can trade o f f elements of t h e i r national s e c u r i t y for increased commercial or other benefits. States are even l i k e l y to do t h i s i f i t enhances t h e i r o v e r a l l p o s i t i o n w i t h i n the i n t e r n a t i o n a l system. As such, s t a t e s are l i k e l y to 15 collaborate when i n d i v i d u a l action does not lead to the best outcome in terms of national interest. States w i l l collaborate to avoid a particular outcome or to ensure an optimal solution to a common problem. 5 States w i l l a l s o p a r t i c i p a t e i n i n t e r n a t i o n a l regimes to overcome the b a r r i e r s to more effecient cooperation, as they not only establish negotiating frameworks, but also f a c i l i t a t e decision-making by coordinating actor expectations and providing high quality informations. 6 LIBERALISM Where c l a s s i c a l realism's expectations of i n t e r n a t i o n a l collaboration i s small, and structural realism more optimistic, liberalism i s certain that increased collaboration w i l l occur, l a r g e l y as a r e s u l t of m o d e r n i z a t i o n . 7 T h i s school of i n t e r n a t i o n a l r e l a t i o n s theory believes that increases i n collaboration are inevitable as relations 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 century coming f u l l y into force, trade has grown immensely and states have come into greater contact and c o n f l i c t with one another than ever before. As a d i r e c t r e s u l t t h i s theory would argue that the structure of international society has changed completely. 8 The c l a s s i c goals of the r e a l i s t s , power and security, have been expanded or superceeded by goals of wealth and welfare. Maintaining the security of i t s geographical boundaries has become le s s important for states than providing wealth and social welfare goals for citizens, states, in order to provide 16 for these new demands, have increasingly been forced to collaborate with one another, and in the process, to surrender some degree of t h e i r p o l i t i c a l autonomy. The key deciding factor in collaboration i s whether this action w i l l result in greater economic prosperity for a nation state, which i s valued above a l l else. States have faced a dilemma: whether i t was preferable to maximize the benefits of increased collaboration or to preserve p o l i t i c a l autonomy, as the benefits of close economic relations can be enjoyed only at the expense of giving up a c e r t a i n amount of national independence or autonomy i n setting and pursuing economic objectives. 9 E s s e n t i a l to the l i b e r a l conception i n i n t e r n a t i o n a l r e l a t i o n s i s the philosophy of Adam Smith. His b e l i e f i n a harmony of i n t e r e s t s — that the actions of i n d i v i d u a l s f u l f i l l i n g their own self-interest would result in an increase in the common good for a l l through the action of the inv i s i b l e hand -- forms the foundation of the p o l i t i c a l b e l i e f s of the l i b e r a l s . As a consequence of his theory, l i b e r a l s believe that the l e s s government r e s t r i c t i o n s and regulation i n the l i f e of private individuals, the better. Following l o g i c a l l y from the above argument, the less restrictions that were placed upon international trade, the greater the return on investment which would r e s u l t i n a larger increase i n wealth for a l l states. According to l i b e r a l theorists Richard Cooper and Edward Morse, states are no longer concerned s o l e l y with mazimizing 17 t h e i r security. Instead of s t r i v i n g for power i n terms of mil i t a r y might, a state's main interest i s in economic issues and i n the scope and terms of trade. The true problem now facing states i s how to keep the manifold benefits of extensive economic intercourse free of crippling restrictions, while at the same time preserving a maximum degree of freedom for each nation to pursue i t s legitimate economic objectives. 1 0 This conundrum i s the r e s u l t of modernization f o r c e s -- the corresponding centralization of government institutions and the predominance of domestic goals over external ones. As a state's wealth i n c r e a s e s and every member of s o c i e t y experiences this improvement, internal demands are made for an expansion of t h i s wealth: "once economic growth reaches high levels and s i t s as a continuous dynamic process increasing the r e a l wealth of most members of society.... minds [turn] away from those foreign p o l i c y goals pursued by r u l i n g e l i t e s of monarchical Europe and toward the further development of domestic wealth through domestic means and under peaceful c o n d i t i o n s . " 1 1 States are, therefore, w i l l i n g to give up p o l i t i c a l autonomy and sovereignty to achieve t h e i r economic goals. This contradicts the r e a l i s t perspective that maintains that states w i l l s t r i v e , above a l l else to maintain t h e i r p o l i t i c a l autonomy and security. For L i b e r a l s the r o l e of the n a t i o n s t a t e has a l s o changed. The t r a d i t i o n a l power of the s t a t e has been undermined to a certain extent by the resulting interdependence 18 of nations conducting trade with one another. A state no longer has t o t a l control over i t s productive capacity and wealth i f i t r e l i e s on other states f or raw materials or markets. Although Cooper and Morse's writings are specific to the post World War Two era, the developments of modernization forces had their beginnings in the technological advancements and trade l i b e r a l i z a t i o n movements of the ninteenth century. FUNCTIONALISM Functionalism, as espoused by David Mitrany, shares many of the underlying assumptions of the l i b e r a l s and t h e i r c r i t i c i s m s of the r e a l i s t view of the world. Present i s a b e l i e f i n the goodness of human nature and a harmony of in t e r e s t s u l t i m a t e l y guiding human action. Mitrany also believes that the nation state, constantly striv i n g for power and security, i s the cause of war. His remedy for t h i s s i t u a t i o n i s f o r the t r a d i t i o n a l form of government to be superceeded by s u p r a n a t i o n a l f u n c t i o n a l organizations. Designed to provide highly t e c h n i c a l functions that could no longer be performed e f f i c i e n t l y or e f f e c t i v e l y by national governments, these organizations would gradually grow in scope u n t i l a web of interdependence would link the interests of a l l countries, causing an end not only to war, but eventually to the nation-state i t s e l f : "functionalism overlays the p o l i t i c a l divisions with a spreading web of international a c t i v i t i e s and agencies i n which and through which the i n t e r e s t s and l i f e of a l l nations would be gradually integrated." 1 2 / 19 According to functionalism, a key factor i n determining the p o s s i b i l i t i e s of internatiional collaboration i s the degree of t e c h n i c a l s p e c i a l i z a t i o n that a transnational problem requires before i t can be successfully resolved. 1 3 For Mitrany the r o l e s of the s c i e n t i f i c e l i t e s who manage these 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 are important. He assumes that technical specialists share common knowledge and approaches and w i l l put aside their p o l i t i c a l loyalties to perform their 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 for the betterment of a l l , not simply for the sake of t h e i r own country. 1 4 There w i l l be no p o l i t i c a l overtones to international collaboration because of the nature of s c i e n t i f i c e l i t e s . This i s a r e s u l t of the highly specialized training technical e l i t e s share; they speak a common s c i e n t i f i c language, have been taught s i m i l a r concepts, and strive for impartiality in achieving s c i e n t i f i c goals. Further, these te c h n i c a l 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. In so doing the lessons of technical cooperation in one international area w i l l spillover to other areas. 1 5 According to Mitrany, humans are c a p a b l e of l e a r n i n g from t h e i r p a s t m i s t a k e s . Collaboration w i l l i n time beget further collaboration. Each of these theories of international relations creates a different perspective to the explanation of the development of cooperation i n i n t e r n a t i o n a l health. Each hi g h l i g h t s c e r t a i n f a c t o r s as being the key to the i n s t i g a t i o n of c o l l a b o r a t i v e e f f o r t s . C l a s s i c a l r e a l i s m considers the 20 s u r v i v a l and s a n c t i t y of the n a t i o n s t a t e to be the overwhelming concern of national leaders. This explains why co l l a b o r a t i o n i n i n t e r n a t i o n a l health was so d i f f i c u l t to achieve i n the f i r s t place. I t further explains why states, even though they may recognize the necessity of common action would refuse to cooperate when their sovereignty or interests were seen as being threatened by i n t e r n a t i o n a l regulation. Liberalism and Functionalism, suggesting that their are other motivations behind foreign p o l i c y such as te c h n i c a l and economic factors, add another facet to the r e a l i s t explanation f o r 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 t was the commercial i n t e r e s t s of states and t h e i r concern for increased wealth through trade that prompted cooperation. And s c i e n t i f i c knowledge had to be advanced to a c e r t a i n stage before collaborative ventures would ensue. The international health regime has in fact s u b s t a n t i a l l y changed from i t s original form and i t has had an effect on the a c t i o n s and m o t i v a t i o n s of i t s members. Obstacles to collaboration have been gradually, yet consistently, removed. There i s now a much greater degree of c o l l a b o r a t i o n i n t h i s area than before. The reasons for t h i s occurence w i l l be examined i n l i g h t of the insights of 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 chapter w i l l review the o r i g i n s of t h i s process, the international 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 Nations: The Struggle  for 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 include Kenneth Waltz, who with his i n f l u e n t i a l book, The Theory of International Relations is one of the pioneers of neo-realism. Other neo-r e a l i s t s , such as Keohane and Nye, f a l l into this category. 5. Arthur Stein, "Coordination and Collaboration: Regimes in an Anarchic World" i n International Regimes, ed. Stephen Krasner, (Ithaca: Cornell University Press, 1983), p. 121-126. 6. Robert Keohane, "The Demand for International Regimes" in International Regimes, ed. Stephen krasner, (Ithaca: Cornell University Press, 1983), p. 150-155, 160. 7. As stated by Edward Morse in Modernization and the  Transformation of International Relations, (New York: The Free Press, 1976), p. 8-9. Modernization i s identified as the resulting specialization, self-sufficiency and level of c e n t r a l i z a t i o n that becomes c h a r a c t e r i s t i c of states a f t e r i n d u s t r a l i z a t i o n . This caused a revolutionary change i n human l i f e : o v e r a l l population expanded as the a v a i l a b l e technology and resources grew to support more people. 8. Ibid, p. 89. 9. Robert Cooper, The Economics of Interdependence: Economic  Policy in the Atlantic Community, (New York: McGraw H i l l , 1968), p. 4. 10. Ibid, p. 5. 11. Morse, p. 80. 12. David Mitrany, A Working Peace System (Chicago: Quandrangle Books, 1966), p. 6. 13. Ibid., p. 27. 22 14. Ibid., p. 39. Also see Inis Claude, Swords into Plough-shares: The Progress and Problems of International  Organization, Fourth 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 of the e a r l i e r i n t e r n a t i o n a l sanitary conferences i s one of nations driven to international negotiation and regulation by a common danger, but completely unable to reach agreement because of the l i m i t a t i o n s of 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 International Sanitary Conferences r e f l e c t s the h i s t o r y of public health i n an i n t e r n a t i o n a l perspective — the f i r s t movement towards what today i s the World Health Organization. This second chapter w i l l document the h i s t o r i c a l progress of European states as they moved towards international regulation in a joint effort, not only to combat the spread of disease, but a l s o to l e s s e n the impediments quarantine measures increasingly posed to growing trade. Despite states' willingness to discuss these issues at the international level, progress was to come slowly to this area. It was to take seven actual conferences before a limited convention could be r a t i f i e d by the necessary countries. The o b s t a c l e s to agreement were, i n p a r t , due to a l a c k of s c i e n t i f i c knowledge as expressed by the dif f e r i n g and opposing views on the transmisibility of pestilent diseases. Cholera, the disease that caused the greatest concern 24 amongst Europeans, was spread through human contact. Governments reacted out of fear and sought to impose a cordon s a n i t a i r e between t h e i r nations and the affected areas. No westward spread of t h i s d i s e a s e had occurred u n t i l the nineteenth century. A special problem controlling the spread of c h o l e r a was presented by the l a r g e number of people p a r t i c i p a t i n g i n the Mecca pilgrimage, most often enduring crowded and unsanitary conditions during their voyage and stay. The quarantine p r a c t i c e s of the day were a r b i t r a r y and often destructive, r e s u l t i n g i n considerable damage to both ships and t h e i r cargo. Goods were confiscated, or destroyed and travellers were subject ot extensive periods of quarantine i n questionable establishments that were v i r t u a l prisons. Clean b i l l s of h e a l t h , which were necessary to escape quarantine procedures, were often fradulent, being highly susceptible to bribery. Quarantine practises were based to a great extent on s u p e r s t i t i o n and hersay, rather than on s c i e n t i f i c knowledge and fact. 1 Countries were in fact best p r o t e c t e d by the development of good p u b l i c h e a l t h and sanitiation services, which would greatly reduce the number of cholera attacks. Unfortunately, i t was to take many years before the contagions of the major diseases were identified and these facts confirmed. Opinions concerning the spread of these epidemic diseases were divided into two main groups, the contagionists, who believed that diseases such as cholera were spread through 25 d i r e c t human contact, and the a n t i - c o n t a g i o n i s t s , or sanitationists who believed that the causes of cholera lay in unsanitary conditions of the victims' l i v i n g quarters, food production and s a n i t a t i o n disposal. The B r i t i s h medical scientists were proponents of the la t t e r position, while most of the other countries' physicians found credence i n the former, contagionist explanation. Undoubtedly the B r i t i s h p o s i t i o n had much to do with t h e i r commercial in t e r e s t s . England had the most advanced sanitary system and public health care system, as well as being geographically removed from the source of the spread of epidemics, the Middle East. As a consequence, B r i t a i n was fa r less affected by these diseases than were other European nations. As anti-contagionists, the Br i t i s h f e l t that quarantine measures were as l i k e l y to f a i l as they were to succeed. They further believed that medical inspection of ships and cargo at points of departure and a r r i v a l were as e f f e c t i v e as quarantine i n preventing the spread of disease as well as being f a r less damaging to commercial trade. Other countries would slowly acknowledge the l o g i c of the B r i t i s h argument as t h e i r own t r a d i n g interests grew. As well as the growing medical controversy regarding quarantine, there was a l s o p o l i t i c a l o p p o s i t i o n to i t s imposition on the grounds that i t was an instrument of state interference i n private commerce. Some suspected that i t was used for a l t e r i o r motives such as espionage. 26 In Europe cholera had only recently appeared in epidemic form, previously being confined to Central Asia and India. I t was considered a new and t e r r i f y i n g disease to Europeans who had not experienced a s i m i l a r s i t u a t i o n since the plague epidemic two centuries previously. Five cholera pandemics, beginning i n 1818, were to s t r i k e Europe over the next f i f t y years. As a r e s u l t of mounting pu b l i c fear, states quickly increased ex i s i t i n g quarantine practises which began to place severe pressure on the growing trade of European countries. 2 Gradually, these obstacles were to force states to consult and devise measures against the common p e r i l these epidemic diseases posed. THE FIRST INTERNATIONAL SANITARY CONFERENCE: PARIS, 1851 The f i r s t p r o p o s a l f o r an I n t e r n a t i o n a l S a n i t a r y Conference was made by the French Sanitary Service as early as 1834, with the B r i t i s h l a t e r proposing one i n 1843. Administrative d i f f i c u l t i e s , and a f a i l u r e to agree on i t s necessity, were to pre-empt t h i s conference for sixteen more years. Landlocked c o u n t r i e s such as A u s t r i a , who were consequently less affected by the last cholera epidemic f e l t that the idea of an i n t e r n a t i o n a l conference was premature. 3 When cholera reappeared i n the t h i r d epidemic wave that century, i t was f i n a l l y concluded that this was a problem that must be approached and solved at the international level. The F i r s t International Sanitary Conference was convened in Paris on July 27, 1851. As the French Foreign Minister stated in his 27 opening address to the conference: " t h i s was [to be] an age where a l l the industries of the universe seemed to have forgotten their former r i v a l r i e s to join hands"4 Twelve countries attended t h i s conference; a l l were European and were represented by both a medical doctor and a diplomat, the l a t t e r to represent the commercial interests of their countries. 5 The objective of this f i r s t conference was to "regulate in a uniform way the quarantine and lazarattos in the Mediteranean." Yet the debate at the conference was as much about epidemiological theories of the diseases between the r i v a l contagionist and s a n i t a t i o n schools, as i t was about standardizing quarantine regulations. This was a pattern to be repeated at future conferences. The United Kingdom was the s t r o n g e s t opponent of quarantine, arguing the i t was t o t a l l y impotent in preventing the spread of epidemic diseases, whereas the Mediterranen countries as well as Russia were in favour of s t r i c t quarnatine measures. France was d i v i d e d between i t s r e g i o n s ; the Mediterranen ports approved of s t r i c t quarantine, while the Northern ports f e l t i t threatened their commercial interests. 6 A f t e r s i x months of debate, f i v e of the twelve countries had reached agreement on 137 a r t i c l e s that were to form the f i r s t I nternational Sanitary Code. This code was not to be a success, however; i t was r a t i f i e d by only three countries and two l a t e r withdrew because of an i n a b i l i t y to carry out the requirements. 28 Despite the apparent failure of this conference in terms of securing a l a s t i n g agreement, i t provided an important precedent in many respects. A number of important principles had been agreed upon, which would l a t e r be embodied i n i n t e r n a t i o n a l quarantine practises. I t was agreed that quarantine was not applicable to ships with a clean b i l l of health; that maximum and minimum periods of quarantine were to apply, d i f f e r i n g for each disease (plaugue, cholera and smallpox); that lazarettos should be hospitals, not prisons, and that quarantine dues should be uniform and not regarded as a source of revenue.7 THE SECOND INTERNATIONAL SANITARY CONFERENCE: PARIS, 1859 As the f i r s t Sanitary Conference was clearly a failure by 1856, w i t h the withdrawl of P o r t u g a l and S a r d i n i a , the remaining signatory, France, proposed another i n t e r n a t i o n a l conference for 1859. I t s objective was to d r a f t a convention that embodied the p r i n c i p l e s of the f i r s t code that would be a c c e p t a b l e to a l l c o u n t r i e s . As there had been great disagreements between the s c i e n t i f i c experts the time before, only diplomatic delegates were sent. This time the p o l i t i c a l unrest of Europe and wide disagreement over the basic aims and elements of the convention were to keep new regulations from being concluded. Instead, the f i n a l d r a f t contained only recommendations, was signed by the delegates of only eight countries, and was promptly forgotten, never to be r a t i f i e d . C o u n t r i e s ' views on the u t i l i t y of quarantine had not 29 s i g n i f i c a n t l y a l t e r e d from t h e i r stances at the F i r s t conference, eight years previously. THE THIRD INTERNATIONAL CONFERENCE: CONSTANTINOPOLE, 1866 In much the same way that the t h i r d onslaught of cholera had galvanized the European countries into i n i a t i n g the F i r t Sanitary Conference i n 1951, the fourth wave of the cholera pandemic p r e c i p i t a t e d the t h i r d conference. The delegates of sixteen countries met at Turkey's i n v i t a t i o n to discuss the or i g i n s of cholera, i t s t r a n s m i s s i b i l i t y and propogation, s p e c i a l preventative measures with regards to the Mecca pilgrimage such as hygiene, quarantine and d i s i n f e c t i o n , as well as the route the 1865 pandemic had taken. 8 The objective of this conference was to find an effective means of a r r e s t i n g the spread of cholera, rather than the coordination of quarantine measures, which had been the main concern of the two previous conferences. The conclusions this conference came to were suprisingly accurate, despite the fact that cholera vibro would not be s c i e n t i f i c a l l y determined for another seventeen years. At this conference delegates agreed i t was unlikely that cholera would become endemic in Europe as i t was i n In d i a , along the Ganges Riv e r . I t was al s o determined that the Mecca Pilgrimages were an important source for the spread of this disease, either through maritime routes, or alternately through r a i l . 9 On the basis of the above conclusions, the French proposed the immediate appointment of a committee to consider the 30 imposition of a ban an a l l maritime communications between Arabian ports and Egypt i f cholera was again to break out amongst the p i l g r i m s . The c h a i r - e l e c t , Stuart of Great Britain, moved, however, his committee be dissmissed as i t was not yet determined how cholera was transmitted. He further stated that he considered i t to be his task, as the B r i t i s h delegate, to oppose any measures that would cause interference with trade, unless their necessity could be proven. 1 0 The Asian countries of Turkey and Persia also objected to t h i s measure on the basis that i t v i o l a t e d the sovereignty of the Muslim countries by imposing the customs, doctrines and l o g i c of European nations on t h e i r s u b j e c t s . 1 1 Other delegates objected on the grounds that i t would place the pilgrims in a considerable predicament i f they were forced to return over land, through the desert, or worse, remain in Mecca i n d e f i n i t e t l y . Countries such as France, Portugal, Prussia and Spain, who f e l t they had a greater need for quarantine and possessed a greater b e l i e f i n i t s e f f i c a c y , urged that the committee proceed with i t s original task of imposing a ban on communication between Egypt and other Arabian ports. It was f i n a l l y agreed that an o f f i c i a l quarantine would be imposed i f cholera did again break out at the s i t e of the pilgrimages. As this convention was never signed, 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 conclusion. Of 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 agreed with the rest of the delegates that: "Asiatic 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 India, where i t a r i s e s and where i t e x i s t s i n a permanent endemic s t a t e . " 1 2 This point was to be l a t e r denied by B r i t a i n at subsequent conferences due to the implications i t would have for B r i t i s h ships transversing the Suez Canal. Already 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, for at t h i s conference they were not prepared to admit that cholera was exported from India by ships flyi n g the B r i t i s h flag. Britain did, however, admit to having a s p e c i a l r e s p o n s i b i l i t y with regards to c o n t r o l l i n g the spread of cholera from India, for which i t proposed a series of sanitary improvements designed to contain this disease. While no conventions resulted from t h i s conference, i t marked an advance i n i n t e r n a t i o n a l p u b l i c health. Sound p r i n c i p l e s were established for the control and spread of cholera at the Mecca pilgrimages, with emphasis placed upon the importance of measures being taken before departure. 1 3 Yet the divergent positions of many countries regarding the principle of quarantine remained firmly in evidence. Issues of national interest prevented states from reaching an agreement. Turkey was concerned about i t s i n t e r n a t i o n a l reputaion, i t s prestige and p o l i t i c a l autonomy. Great B r i t i a n 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, and other European c o u n t r i e s were genuinely concerned with a r r e s t i n g the spread of cholera, regardless of the negative effects their provisions would have on other countries. 32 THE FOURTH INTERNATIONAL SANITARY CONFERENCE: VIENNA, 1874 The Fourth International Sanitary conference was proposed by Russia i n an e f f o r t to gain r e l i e f from the damaging quarantine regulations imposed along the Danube River. The o f f i c i a l objective of the twenty-one states that attended this conference was to re-examine and codify the conclusions that were made at the Third Conference, eight years previously. The delegates to this conference were almost a l l medical scientists and the debate concerning the transmission of cholera continued unabated from previous years. This debate can clearly be seen i n the commissions that were convened to prepare dra f t l e g i s l a t i o n for the regulation of quarantine in Europe. While i t was e a s i l y agreed that land quarantine, considered to be "unworkable and consequently useless", should be abolished, the s i t u a t i o n was to prove more confrontational with regards to maritime quarantine. 1 4 Originally the committe proposed that quarantine should be replaced by rigorous medical inspection. This committee was largely composed of Northern European states, and the Southern states, who were more supportive of quarantine measures, moved that the committee be asked to make a further report, taking into account the "special conditions of quarantine in certain s t a t e s of Southern Europe". They a l s o requested that additional members representing these states should be added to the committee. 1 5 While t h i s motion was defeated i t was decided that the committee's report should be revised to 33 include both principles of quarantine and medical inspection, but that they should only be recommendations, with each state being free to choose between the two, as long as they were a p p l i e d i n an uniform f a s h i o n . The l a c k of s c i e n t i f i c knowledge and the c l e a r differences i n the perceived s e l f -i n t e r e s t of Northern and Southern states was to prevent a successful conclusion'of a sanitary conference for twelve more years. Although t h i s conference reached few conclusions, one p o s i t i v e development lay i n i t s proposal for a permanent i n t e r n a t i o n a l commission on epidemics. I t was declared that such an ins t i t u t i o n would be valuable "from the t r i p l e point of view of s c i e n c e , humanity and i n t e r n a t i o n a l m a t e r i a l i n t e r e s t s . " 1 6 I t s d u t i e s were to i n c l u d e the study of epidemics; to present reasoned advice on the establishment and a d m i n i s t r a t i o n of quarantines; to c o n s u l t with s t a t e s regarding the above two topics, and to propose the convening of future i n t e r n a t i o n a l sanitary conferences when necessary. Despite the fac t that t h i s proposal was unanimously well recieved by the delegates i t was not to be acted upon for almost t h i r t y years. I t was not u n t i l 1907 that the O f f i c e International d'Hygine Publique (OIHP) f i n a l l y came into being. At t h i s time, c e r t a i n governments were reluctant to act upon t h i s proposal; they doubted the use and necessity 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 that i t would be of l i t t l e use: "we must confess to want of faith," reported 34 the B r i t i s h delegate, " i n the value of c o - o p e r a t i v e international s c i e n t i f i c work".17 Despite the fact that this proposal was not well received then, the OIHP differed l i t t l e from the guidelines established at Vienna in 1874. The oppostion of the B r i t i s h to international regulation of health concerns must be understood i n r e l a t i o n to t h e i r views on the u t i l i t y of quarantine. As the foremost trading nation i n the world at t h i s time, quarantine had the greatest detrimental effect upon Britain. As the mood of international conferences often was contrary to B r i t i s h interests, favouring the retention of quarantine i n some form or another, the B r i t i s h usually found themselves to be in the minority. They consequently grew more suspicious of the international sanitary conferences, as the measures they proposed would hamper Britain's significant commercial interests. In the end, t h i s conference added l i t t l e to the development of i n t e r n a t i o n a l sanitary regulations, for i t f a i l e d to reach consensus on any of the proposed resolutions. In fact, the f i n a l document, in approving of both the continued use of quarantine and a l s o 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. Suprisingly, there was l i t t l e discussion of the r a m i f i c a t i o n s of the Suez Canal, opened f i v e years e a r l i e r i n 1869, that would have a dramatic i n f l u e n c e on the spread of c h o l e r a and f u t u r e s a n i t a r y conferences. 35 THE FIFTH INTERNATIONAL SANITARY CONFERENCE: WASHINGTON, 1881 The F i f t h International Sanitary Conference was an anomaly i n terms of the development and p r o g r e s s i o n of these conferences. I t had no l o g i c a l connection to ei t h e r the proceeding or succeeding conferences, and was the only one to be held off the European continent. It was held at the request of the United States of America to secure international assent for a piece of American domestic l e g i s l a t i o n that otherwise would be unenforceable. 1 8 The United States was greatly concerned with controlling the spread of cholera and especially the spread of yellow fever, a disease that was l o c a l i z e d to the Western Hemisphere. The US Congress had passed an Act in 1879 designed "to prevent the i n t r o d u c t i o n of contagious or in f e c t i o u s diseases coming from infected ports abroad." The p r o v i s i o n s of the act r e q u i r e d t h a t a v e s s e l with a US destination possess a c e r t i f i c a t e from a US consular o f f i c i a l " s e t t i n g f o r t h the sanitary h i s t o r y of said v e s s e l " . 1 9 The United States believed that a lack of attention at the point of departure resulted i n the c o s t l y a p p l i c a t i o n of quarantine r e s t r i c t i o n s at destinations, and sought to remove t h i s unnecessary impediment to trade. As the act s t i p u l a t e d that American consular o f f i c i a l s were required to ensure personally the facts on the health c e r t i f i c a t e s , foreign ships would have to be examined by US nationals. Thus, a ship could not embark on i t s voyage i f bound for a US destination u n t i l i t had been boarded i n i t s 36 home port, inspected and given a clean b i l l of health by an agent of a foreign power. Objections were quickly raised to this proposal as i t was regarded as an infringement of national sovereignty as well 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. Spain and Italy, believing their own n a t i o n a l systems of i n s p e c t i o n to be adequate, f e l t particualrly insulted and strongly resented the US's implicit charge. Great Britain, the Netherlands and Portugal suggested instead that each country's medical o f f i c i a l s should be the ones to give b i l l s of health, also resenting the thought of a foreign inspection of their ships. 2 0 This proposal was easily defeated, largely as a result of the implications i t would have had for each country's prestige and national sovereignty. A compromise was reached, however, whereby a consular o f f i c i a l of the country of destination could endorse the b i l l of health and be present at the inspection of a ship, but the sanitary o f f i c i a l of the country of departure would actually issue the c e r t i f i c a t e and conduct the investigation. A significant proposal that emerged from this conference was for the establishment of an international organization to exchange epidemiological information. This suggestion as with the p r e v i o u s conference's pro p o s a l f o r a s c i e n t i f i c organization to study epidemics, was slow in coming to f r u i t i o n and emerged only in 1907, twenty-five years later. An important s c i e n t i f i c discovery that was to have far reaching consequences on the debate between the contagionists 37 and the anti-contagionists or sanitationists was also revealed at t h i s conference. The yellow fever vibro was announced. The proposition that an insect, in this case a mosquito, could be the carrier of a disease, gave credence to both theories and had the effect of suggesting that both should also be followed to some degree. The discovery of the insect vector also formed the basis for the 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 of the typhus and plague vibros, as they too were transferred from person to person through an intermediatary agent. This conference was unique in other ways besides being the only one to be held i n the Western Hemisphere. I t marked the f i r s t appearance of the United States i n t h i s forum, and was the f i r s t t r u l y i n t e r n a t i o n a l sanitary conference, having twenty-six p a r t i c i p a n t s , many from beyond the borders of Europe. Included were seven Latin American countries and even Japan. The breadth of participation demonstrates how great the spread of epidemic diseases was at t h i s time, reaching even into the previously uncontaminated "new world". It also shows how i n t e r n a t i o n a l regulation and action to control t h i s s i t u a t i o n was needed and was becoming more acceptable, i n principle, i f not yet in action, to a l l states. THE SIXTH INTERNATIONAL SANITARY CONFERENCE: ROME, 1885 The Sixth International Sanitary Conference was prompted by the reappearance of cholera in Egypt in 1883. Initiated by I t a l y the objective of t h i s conference was to secure an agreement on standardized requirements for quarantine, which 38 were s t i l l quite archiac despite previous conventions on the same issue. This was to be a p r a c t i c a l conference, without reference to s c i e n t i f i c debate or the causes and mode of transmission of cholera. The major issue of the conference was the regulation of quarantine along the Suez Canal, and despite good intentions, the old arguments of the s a n i t a t i o n i s t s and the contagionists broke out once again. At this time there was s t i l l great s c i e n t i f i c debate over the causes of the spread of cholera. Although the correct means of t r a n s m i s s i o n was i d e n t i f i e d as being through contaminated drinking water as early as 1840 by John Snow and in 1854 by Filippo Pacinni working independently, this fact was not to be recognized f or another h a l f century. Instead the views of Max von Pettenkofer, who believed that the cholera vibro was transmitted through an intermediary agent such as water, s o i l or a i r , held sway. The person normally credited with discovering the cholera vibro, Robert Koch, announced the discovery of t h i s b a c i l l u s i n 1884, and proposed that i t s method of transmission was through contaminated drinking water. 2 1 This was not well recieved by the B r i t i s h , who refuted the idea of a specific contagion, as they had the most to l o s e by a d m i t t i n g t h a t the di s e a s e was spread even indirectly through human intercourse. 2 2 The intensity of this s c i e n t i f i c debate was to prevent the conclusion of a successful sanitary code for another ten years. In the discussions at t h i s conference, Great B r i t a i n , 39 supported by the United States and Denmark, wanted to replace the old method of quarantine with medical inspection. Over t h e i r o b j e c t i o n s , the conference recommended the r e -introduction of a twenty-four hour period of observation for a l l healthy ships passing through the Suez Canal, and a three to six day quarantine for healthy persons from infected ships. I t a l y and Austria-Hungary, f e e l i n g at the greatest r i s k of infection, were the strongest supporters of this re-imposition. Britain and i t s colony, India, were represented by strong anti-contagionists who, throughout the conference, sought to 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 ships removed. This led the other delegates to accuse them of placing t h e i r trading 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 aside the most elementary regard for i n t e r n a t i o n a l s a f t e y . " 2 3 B r i t a i n staunchly defended i t s actions by c i t i n g the fact that cholera had never been directly imported into Europe by a vessel reaching the Mediterranean from the Suez Canel. B r i t a i n further asserted that the idea t h a t c h o l e r a was imported from I n d i a was nothing but a preconcived notion, unsupported by evidence, despite the fact that i t s delegates had agreed to t h i s " f a c t " at the Third Conference some twenty years earlier. In the interval, B r i t i s h trade 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 i n part to the opening of the Suez Canal. Now B r i t a i n maintained that cholera was transmitted by the pilgrimage to the Middle East 40 and then to the rest of Europe. As further proof of the worthlessness of quarantine, B r i t a i n c i t e d the f a c t that despite i t s close connections and trade with India they had not had an epidemic outbreak of cholera for close to twenty years. While the B r i t i s h referred to the lessons they had learned through 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 India as being the reason why they so strongly oppossed quarantine, the damaging effects these measures had upon their trade must also be viewed as a major factor. Four out of every f i v e ships transversing the Suez Canal were B r i t i s h , most of them originating in India. As the B r i t i s h ambassador noted in a l e t t e r to the President of this conference, the three to six day period of quarantine that was suggested would reduce the time saved by u t i l i z i n g the Suez Canal to two days, and add further to the costs associated with the canal, which were already l i t t l e l e s s than the a d d i t i o n a l costs of rounding the Cape i t s e l f . 2 4 As such, the B r i t i s h refused to sign the f i n a l convention and the s i x t h conference was adjourned without results. SEVENTH INTERNATIONAL SANITARY CONFERENCE: VENICE, 1892 The Seventh International Sanitary Conference was to provide the f i r s t l i m i t e d success for these endevours. A l i m i t e d regulatory code was imposed on ships t r a v e l i n g home from the Mecca pilgrimage. Austria-Hungary had proposed this conference and had made sp e c i a l e f f o r t s to secure B r i t i s h participation. Since the last conference, seven years earlier, 41 Britain had not changed i t s position regarding quarantine and was not anxious to resume i n t e r n a t i o n a l discussions on a subject where i t was c o n s i s t e n t l y outvoted. Austria-Hungary promised to "endevour to exclude from discussions at the conference everything that might seem unacceptable to English i n t e r e s t s " . 2 5 Austria-Hungary had r e c e n t l y concluded a protocol with Britain whereby B r i t i s h ships could pass freely through the Suez Canal i f bound direc t l y for a port within the United Kingdom. At the opening of t h i s conference they suggested that other countries agree to a s i m i l a r protocol. The B r i t i s h had proposed this same idea at the last conference i n Rome and now added the promise that sanitary guards would board the vessel for i t s voyage through the Suez to ensure that the ship's passengers and goods did not come into contact with the shore or other ships. This proposal was quickly vetoed by the other countries' delegates who pointed out that there was no method of ensuring a ship could transverse the Suez Canal without meeting objectionable weather forcing i t to land. The German delegation s a r c a s t i c a l l y commented on the "suprising 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 limited agreement was reached, however, concerning the Mecca Pilgrimage. A l l ships returning northwards with foul or unacceptable b i l l s of h e a l t h had to undergo a minimum quarantine period of fifteen days. This instituted a system of protection for Europe against the importation of cholera from 42 the pilgrimage, a measure that was to be reinstituted from time to time even into the twentieth century. This convention was r e l a t i v e l y easy to secure as i t was l i m i t e d to p i l g r i m ships and thus did not encroach upon B r i t i s h commercial maritime interests in the slightest. I t had taken forty-one years to achieve a l i m i t e d i n t e r n a t i o n a l agreement to r e s t r a i n the spread of epidemic diseases. Progress was now to quicken i n t h i s area with the s c i e n t i f i c discovery of many of the vibros of the p e s t i l e n t diseases. The announcement of the ro l e of the insect mosquitoes i n the transmission of yellow fever at the f i f t h conference had been followed by the discovery of the cholera vibro in 1884. Although this discovery i n i t i a l l y supported the views of the contagionists, i t gave future conferences a s c i e n t i f i c base from which these matters could be discussed. Consent was f a r from unanimous as to the cause and means of transmission of the cholera vibro. Was cholera a contagious disease, spread through human contact and foul drinking water, or were i n d i v i d u a l s predisposed to the disease by v i r t u e of some mysterious element, as the B r i t i s h believed? This question was soon to be answered by medical science. EIGHTH INTERNATIONAL SANITARY CONFERENCE: DRESDEN, 1893 The Eighth International Sanitary Conference was again i n i t i a t e d by Austria-Hungary in the hopes of reaching agreement on a set of codified quarantine regulations for Venice in much the same way that the seventh conference had established 43 regulations regarding the Suez Canal. Austria-Hungary was greatly concerned with the serious impact quarantine measures, imposed the year previously as a response to the forth cholera epidemic, had upon both international travellers and commerce. These restrictions were not " j u s t i f i e d by the requirements of a sanitary service based on the results won by modern science". 2 7 Opinions regarding the u t i l i t y of quarantine were beginning to change i n the face of modern developments i n both science and trade, as Austria-Hungary's change in opinions demonstrates. Originally Austria-Hungary did not view quarantine measures as an issue i n need of attention; t h e i r p o s i t i o n then switched within a few years from one of complete d i s i n t e r e s t to being strongly supportive of quarantine measures and, further, to viewing these measures as being obstructive to t h e i r trading interests. Not a l l nations were ready to abandon t h e i r t r u s t i n the values of quarantine, however. When Russia was to propose at the Eighth Conference the removal of a l l sanitary regulations on the Danube River, c i t i n g the damaging e f f e c t s t h i s had on in t e r n a t i o n a l t r a f f i c , t h i s idea was strongly opposed by Romania. As a result, a l l non-infected ships on the Danube had to endure a three day quarantine. In order to secure the support of other nations for t h i s decision, Romaina had to point out that only a minimal amount of Russia's shipping transversed the Danube. This exchange i s evidence of the growing concern that many nations were beginning to f e e l 44 towards the necessity of securing the removal of f i n a n c i a l l y damaging impidements to trade. 2 8 Agreements were quickly reached on the findings of the s c i e n t i f i c committees of the Eighth Conference and i t closed a l i t t l e more than a month a f t e r i t had convened. In the r e s u l t i n g convention ten European nations promised to n o t i f y each other quickly i f any outbreaks of cholera broke out within their t e r r i t o r i e s , and also agreed to specific regulations of what was permissible in their quarantine procedures. The only goods that were to be subjected to restrictions were bed linens and rags, which could either be prohibited or disinfected, but were not quarantinable. Letters and newspapers were to be free of a l l r e s t r i c t i o n s and to t r a v e l f r e e l y between countries. Land quarantine was forbidden and t r a v e l l e r s could only be detained i f they displayed symptoms of c h o l e r a . 2 9 As i t had now become widely accepted that cholera was not i n fact transmitted by d i r e c t human contact, but that unsanitary conditions played a great r o l e i n i t s transmission, these agreements were relatively easy to secure. NINTH INTERNATIONAL SANITARY CONFERENCE: PARIS, 1894 The French i n i t a t e d the proceedings f o r the Ninth International Sanitary Conference to complete the process that had begun with e a r l i e r conferences, the sanitary control of the Mecca pilgrimages. At i t s opening, the President of the conference stressed the need to eliminate once and for a l l the major factors in the westward spread of cholera, which had been 45 determined e a r l i e r at the Seventh Conference in Venice (1892). At t h i s time states had agreed on steps to prevent cholera from spreading to Egypt and the Mediterranean. This minor success was followed by the Eighth Conference in Dresden (1893) where states agreed to a system of notification for the outbreaks of cholera and on the maximum precautions to be taken in the event of a such an occurance. 3 0 The approach taken at this Ninth Conference was to d i f f e r s i g n i f i c a n t l y from previous ones, as countries were now less concerned with the regulation of quarantine than with the reduction of the p o s s i b i l i t y of the spread of disease at i t s source, the p i l g r i m a g e s themselves. By t h i s time the s a n i t a t i o n i s t s had l a r g e l y defeated the r i v a l contagionist school, hence the a t t e n t i o n devoted to p r e v e n t i n g the transmission of cholera at i t s source. A convention was drawn up that included: proposals for mandatory hygiene on pilgrim ships, the establishment of additional f a c i l i t i e s on the route of the pilgrimage, and a "means t e s t " f o r the p i l g r i m s at t h e i r point of departure. This l a s t item was the source of strenuous objections from Britain and from Turkey whose assent would be necessary before the code could be put into practise. Turkey r e f u s e d to s i g n t h i s convention on c u l t u r a l and religious grounds; i t reported that the pilgrimage was one of the five basic commandments of the Muslim rel i g i o n and i t could not be forbidden by any i n t e r n a t i o n a l convention or code. Britain's r e f u s a l was, i n part, due to the impossible burdens this would have placed upon their Indian colony. This position also must be seen as reflective of their assertion that cholera was not endemic to India. As the two countries whose assent was v i t a l f or the Ninth Convention to be put into p r a c t i s e r e f u s e d to s i g n , t h i s conference added l i t t l e to the development of i n t e r n a t i o n a l sanitary regulations. I t i s s i g n i f i c a n t , though, that i t was the t h i r d such conference i n the short space of two years, demonstrating the importance and urgency that states were beginning to place on i n t e r n a t i o n a l action to control the spread of epidemic diseases such as cholera. TENTH INTERNATIONAL SANITARY CONFERENCE: VENICE, 1897 This Conference d i f f e r e d from past conferences i n one major respect. While the others had been convened to deal s p e c i f i c a l l y with cholera, (with the exception of the f i f t h that was p r i m a r i l y concerned with yellow fever), the primary purpose of the Tenth was to discuss methods to c u r t a i l the epidemic of plague that was then spreading throughout Europe. Austria-Hungary had proposed this meeting out of fear that i t s p i l g r i m s would return with t h i s disease. Many European countrie had already forbidden t h e i r c i t i z e n s to attend the pilgrimage and others such as Austria-Hungary adopted special measures to deal with this looming health c r i s i s . The f i r s t order of business for t h i s conference was to secure the r a t i f i c a t i o n of the 1894 convention on cholera. This effort met with l i t t l e success except for the addition of 47 B r i t a i n as a signatory. A new convention was drawn up, however, and signed by eighteen countries. It dealt with both external and internal European measures to control the plague, the disinfection of ships and goods, and the surveillance that was to be performed by the Egyptian and Constantinoplian Sanitary Councils. A provision that healthy passengers and ships were to be given free passage regardless of the state of the b i l l s of health was adopted, demonstrating the advances that had been made i n defeating the p r i n c i p l e of quarantine. Obligatory telegraphic n o t i f i c a t i o n of the f i r s t cases of plague was also unanimously accepted by a l l countries, even those that did not sign the convention, namely the United States and Denmark. Nation-states were beginning to r e a l i z e the importance of epidemiological information being relayed between countries as e f f e c t i v e t o o l s i n c o n t r o l l i n g the outbreak and spread of pestilent diseases. Despite the promise of a l l signatories to implement immediately this convention, i t was not to provide much r e l i e f for shipping i n t e r e s t s , as i t was r e a l l y a patchwork of solutions. To remedy this situation, the suggestion was made that a t e c h n i c a l commission be established to harmonize and codify the four previous conventions, although this practical solution would not be acted upon for six years. ELEVENTH INTERNATIONAL SANITARY CONFERENCE: PARIS, 1903 The convening of t h i s conference was a r e s u l t of many factors. In the f i r s t place, i f only for administrative 48 purposes, there was an obvious need to c o n s o l i d a t e the accomplishments of the last four conferences into one coherent document. Second, a congress of shipping interests meeting at Vienna i n 1902 had strongly recommended to t h e i r respective governments that another sanitary conference be convened for the same purpose 3 1. Trade was by now an important source of national revenue for a l l European states. Competition amongst them was f i e r c e as they sought to secure as much p r o f i t from their overseas colonies as possible. As liberalism ruled 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 in Paris during the f a l l of 1903 at the invitation of Italy. This conference had been convened in the belief that new s c i e n f i t i c knowledge of the etiology of p e s t i l e n t diseases c a l l e d for a r e v i s i o n of the e x i s t i n g international sanitary codes. 3 2 It had been determined since the last conference in 1897, which had dealt almost exclusively with the plague, that rats played a fundamental r o l e i n the epidemiology of this disease. It had also by now become known through s c i e n t i f i c discoveries and medical advances that the main items to be eliminated or neutralized i n c o n t r o l i n g the spread of p e s t i l e n t diseases such as cholera, the plague, and yellow fever, were unsanitary l i v i n g conditions, rats and insects such as fleas and mosquitos 3 3. Yellow fever, s t i l l regarded p r i m a r i l y as a North American issue, was not to be considered. This conference, as with the previous ones, was 49 designed to protect Europe from the exotic diseases of other lands with which i t came into contact through trade. The countries of the Americas were thus tackling health issues by themselves. Two American Sanitary Conferences had already led to the creation of the Pan American Sanitary Bureau in 1902. The Eleventh Conference had i n fa c t succeeded i n i t s objective of u n i t i n g the four previous conventions into one international sanitary code. It was signed by twenty countries, and by 1907 sixteen of them had r a t i f i e d the convention. This s i n g l e code replaced the near anarchy that had previously existed with various conventions regarding the imposition of quarantine. The period of allowable quarantine was further reduced from fifteen days to a maximum of five. In practise i t was becoming increasingly popular to replace quarantine with a system of medical inspection. Moreover, the new convention contained two obligatory p r i n c i p l e s . The f i r s t was the necessity of a state informing a l l other signatories of the appearance of an epidemic disease within t e r r i t o r y under i t s jurisdiction. The second was that states, upon being notified of such a s i t u a t i o n , would not impose measures against the a f f l i c t e d country i n excess of what was prescribed by the convention. 3 4 These p r i n c i p l e s were based on the lessons learned over the past h a l f century of i n t e r n a t i o n a l disease control. While i t was important to control the spread of disease, i t was now agreed that measures could not unecessarily interfere with trade. These two principles formed the basis 50 of the international health regulatory regime and remain today as essential components. CONCLUSIONS - THE EARLY CONFERENCES Although i t seems as though the e a r l y conferences accomplished l i t t l e , they did i n fact contribute slow yet steady progress towards the development of today's health regime. By t h e i r very existence the early conferences led countries to accept i n t e r n a t i o n a l discussion and action on c o n t r o v e r s i a l questions t h a t i n v o l v e d domestic medical practises and trade questions, which previously would have been regarded as issues of national j u r s i d i c t i o n only. They also brought arbitrary and corrupt quarantine practises under the scrutiny of public debate. In demonstrating the damaging effects and the inadequacy of the contagionist theories, these conferences quickened the search f o r more r a t i o n a l and s c i e n t i f i c premises to explain the spread and the necessary treatment for these pestilent diseases. 3 5 The French delegate to the Eleveth conference (who had attended a l l since 1871, with the exception of the Fifth) pointed out, "that although i t appears that the f i r s t s i x conferences accomplished l i t t l e , with no conventions resulting, they had in fact, contributed to the disappearance of excessive, absurd and even barbarous measures". 3 6 A f t e r f i f t y - t h r e e years an acceptable and i n c l u s i v e sanitary code was duly signed 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 international health regulatory regime had 51 been created. I t contained two e s s e n t i a l p r i n c i p l e s that remain i n the health regime today, although i n a somewhat diluted from. The f i r s t was to contain the spread of epidemic diseases, and the second wass to ensure the f i r s t without imposing unnecessary b a r r i e r s to the free flow of goods and commerce. There are also two reasons why t h i s event f i n a l l y came to pass. The f i r s t was undoubtably the mounting pressure that growing trade had placed upon nations to eliminate or, at the minimum, to reduce and standardize the existing quarantine regulations that had proved to be such great impediments to the free flow of trade. Second, advances had been made in medical knowledge and science regarding the sources of these pestilient diseases which allowed states to reach agreement on the most effective methods of controlling the spread of disease. It i s clear that without these two developments, agreement would not have been possible in this area of international collaboration. 52 ENDNOTES - CHAPTER TWO 1. N e v i l l e Goodman, International Health Organizations and  their Work, (London: Churchill 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 of 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 Chronicle of the World Health Organization, Vol, 28., p. 161. 4. The F i r s t Ten Years of the World Health Organiza- tion (Geneva: World Health Organization, 1958), p. 4. 5. Goodman, p. 43. 6. H. S. Gear and R. Duetchman, "Disease C o n t r o l and International Travel: A Review of International Sanitary Regulations", i n Chronicle of the World Health Organ- i z a t i o n , Vol, 10-11., p. 277. 7. Gear and Deutchman. p. 277. 8. Ibid., p. 279. 9. Howard-Jones, p.2 3 6. 10. Ibid., p. 235. 11. Goodman, p. 55. 12. Gear and Deutchman. p.236-237. 13. Goodman, p. 58. 14. Howard-Jones, p.245. 15. Ibid. Italy was the exception. 16. Cited in Goodman, p. 59. 17. Cited in Goodman, p. 60. 18. Howard-Jones, p. 370. 19. Cited in Howard-Jones, p. 370. 20. Goodman, p. 61. 53 21. Howard-Jones, p. 376. 22. Ibid., p. 379. 23. Cited in Gooman, p. 64. Quotation i f from a speach by the French Delegate, quoting an a r t i c l e that appeared in the Hungarian Press. 24. Howard-Jones, p. 384. 25. Cited in Howard-Jones, p. 419. 26. Cited in Howard-Jones, p. 414. 27. C i t e d i n Howard-Jones, p. 414. Included i n the introductory address made by the Austo-Hungairian delegate at the Eighth Conference. 28. Ibid, p. 426. 29. Ibid. 30. Ibid, p. 455. 31. Gear and Deutchman, p. 281. 32. Howard-Jones, p. 464. 33. Ibid, 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 h e a l i n g and the prevention of disease i s e s s e n t i a l l y world-wide, the technical method of i t s a p p l i c a t i o n had been too often l i m i t e d by politico-geographical boundaries. — Melville D. Mackenzie The successful adoption of an international sanitary code i n 1903 a f t e r almost f i f t y years of e f f o r t was to foreshadow the achievements of international public health this century. This chapter w i l l be concerned with outlining the developments o r i g i n a t i n g i n the l a t t e r part of the ninteenth century that manifested themselves i n both the creation 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 and i n the adoption of s e v e r a l comprehensive sanitary codes. These developments were largely the result of the changing s c i e n t i f i c philosophy for treating epidemic diseases. Quarantine was increasingly being replaced by a p o l i c y of disease containment. Instead of erecting b a r r i e r s to prevent the spread of disease i t was decided to contain disease through epidemiological surveillance. This had become i n c r e a s i n g l y necessary as new developments i n transportation reduced international travel time to below the p e r i o d of i n c u b a t i o n f o r most di s e a s e s . As a r e s u l t , quarantine was no longer an effective means of disease control. 55 I t was r e a l i z e d that epidemic diseases must be arrested at t h e i r source, before they could spread to other populations. This philosophy of disease containment was not to be f u l l y realized u n t i l the creation of the World Health Organization in 1948. The seeds of this philosophy can be recognized, however, i n the actions and deeds of the Health Organization of The League of Nations and the health organization that preceeded i t . ORGANIZATION INTERNATIONAL D'HYGIENE PUBLIQUE 1907-1948 Acting upon a recommendation from the last International Sanitary Conference in 1903, the f i r s t permanent international h e a l t h o r g a n i z a t i o n , the O f f i c e I n t e r n a t i o n a l d'Hygiene Publique (OIHP) was founded i n 19 07 at a conference i n Rome. This organization was to be located i n Paris, with the French also taking r e s p o n s i b i l i t y for d r a f t i n g the c o n s t i t u t i o n , reflecting their long-standing interest in international health r e g u l a t i o n . 1 T h i r t e e n c o u n t r i e s attended the inaugural conference and with the exception of B r a z i l and the United States, the delegates were a l l European. Notable for t h e i r absence were the countries of Germany, Austria-Hungary and Scandinavia. The purpose of the Paris O f f i c e , as the OIHP soon became known, was: "to c o l l e c t and bring to the knowledge of the p a r t i c i p a t i n g states the facts and documents of a general character which r e l a t e to public health, and e s p e c i a l l y as regards i n f e c t i o n s diseases, notably cholera, plague and 56 yellow fever, as well as measures taken to combat these diseases." 2 This o f f i c e was also to provide a l i n k between medical and s c i e n t i f i c advances throughout the world and to keep the sanitary conventions up to date. In actual practise, however, the organization was l a t e r to take on a much greater role in international health regulation. Most importantly the Paris O f f i c e became a c l e a r i n g house f o r epidemiological information. Future sanitary conferences were to bestow upon the o f f i c e the duties or recieving, organizing and transmitting to members' public health o f f i c e s information regarding the status of communicable diseases such as the plague, cholera, yellow fever, typhus and smallpox, as well as l i s t s of ports with sanitary equipement for d e r a t i f i c a t i o n . Gathering t h i s i n f o r m a t i o n enabled the o f f i c e to p u b l i s h the Weekly Epidemiological Report, which was useful i n ensuring the compliance of the S a n i t a r y Codes, as n a t i o n s who were t r a d i t i o n a l l y concerned about f a l l i n g prey to a spreading epidemic were able to ascertain the true status and r i s k a disease posed to them. Gathering such information was the f i r s t step in epidemiological disease containment. The need f o r an i n t e r n a t i o n a l health i n s t i t u t i o n had f i n a l l y , after many years of discussion, become obvious, as had the need for a c e n t r a l unit to i n t e r p r e t and monitor the sanitary conventions. The coordination of research under one o r g a n i z a t i o n avoided c o s t l y d u p l i c a t i o n of s c i e n t i f i c enquiries, saved time, e f f o r t and money, and ensured that 57 epidemiological information was quickly transmitted to a l l members. A l l states would now have the benefit of s c i e n t i f i c knowledge and expert assistance. 3 The Paris Office held i t s f i r s t meetings on the fourth in November, 1908, with nine countries attending. And although this meeting produced l i t t l e practical results, i t i s important to observe that i t s o r i e n t a t i o n d i f f e r e d l i t t l e from the a t t i t u d e of the early sanitary conferences. Once again the e s s e n t i a l aim of the excerise was to protect Europe from the importation of cholera and the plague. 4 Consumed largely with administrative details, this conference did not actually begin to discuss the technical questions of pestilent diseases u n t i l the spring of 1910. The health agenda was also s i g n i f i c a n t l y broadened; where the focus had previously been on contagious d i s e a s e s such as c h o l e r a , the plague, smallpox, and occasionally yellow fever, b i l o l o g i c a l standardization had now become a t o p i c for i n t e r n a t i o n a l action. For example, discussions took place on the necessary measures to ensure that the diptheria antitoxin was of equal potency in every country. Attempts were also made to coordinate the reporting weeks for h e a l t h s t a t i s t i c a l p u r p o s e s . These e f f o r t s at the standardization of epidemiological reporting were to be c o n t i n e d under the a u s p i c i e s of f u t u r e i n t e r n a t i o n a l organizations as well. The Paris O f f i c e began preparations for the r e v i s i o n of the Sanitary Convention of 1903 at i t s f i f t h session. Members 58 agreed at t h i s time that the sanitary precautions regarding cholera would be the main item on the agenda, with some discussion on plague and yellow fever a c t u a l l y taking place. The membership of t h i s organization had expanded beyond the confines of Europe; i t had risen from nine to twenty-two states i n j u s t two short years. Now delegates from as f a r away as A u s t r a l i a , A l g e r i a and even Canada attended, and countries that had ear l i e r expressed reservations about joining the Paris Office agreed to send delegates to this prepratory meeting. A notable exception was Great Britain and India, relying not for the f i r s t time i n the h i s t o r y of the sanitary conferences on t h e i r own judgement regarding health safeguards and the imposition of quarantine. TWELFTH INTERNATIONAL SANITARY CONFERENCE: PARIS, 1912 The Twelfth International Sanitary Conference was attended by forty-one countries, including China, Siam and sixteen delegations from Latin America. Although this conference had no formal connection with the OIHP other than prepatory consul, i t made use of OIHP studies and background material, and the s t a f f of the P a r i s O f f i c e were i n v i t e d to attend and participate in the deliberations. 5 As i t had by now been s c i e n t i f i c a l l y determined that healthy persons could carry the cholera vibro, the question repeatedly r a i s e d at t h i s conference was how long could an otherwise healthy person be reasonably quarantined? Despite the fact that international commercial interests desired less 59 rigorous quarantine periods, the general public exerted great pressure on states to retain quarantine as protection against these pestilent diseases. In the end i t was decided that "in a country where sanitary conditions are good, the danger of the importation of cholera by germ carriers i s minimal". It was to be l e f t to i n d i v i d u a l countries to decide whether further bacteriological testing would be necessary. 6 The l a s t meeting of the OIHP had confirmed the r o l e that rats played i n the transmission of bubonic plague. I t was therefore strongly recommended at this time that a l l merchant ships undergo systematic and periodic deratting of their ships, to control the spread of this disease. Yellow fever was again r a i s e d i n discusssion as a disease m e r i t i n g i n t e r n a t i o n a l a t t e n t i o n , but as i n previous conferences i t was p e r c e i v e d to be a "North American phenomena". Therefore, and i n the words of the B r i t i s h delegate, " i t was inappropriate to discuss i t at a European conference." 7 This comment sparked a debate as to whether there should continue to be a d i s t i n c t i o n between the two International Sanitary Conventions, one consisting of European states, the other of non-European states. Besides i n i t i a t i n g their own sanitiary conferences, the Americas had also formed t h e i r own seperate health organization, the Pan American S a n i t a r y Bureau. Created i n 1901 to gather and r e p o r t epidemiological information within the Americas i t had already produced two Sanitary Codes. It s primary function was to s i m i l a r to the OIHP's. I t formulated sanitary agreements and r e g u l a t i o n s with the o b j e c t i v e of reducing quarantine requirements to a minimum.8 Controlling the spread of yellow fever was a major concern of this organization, but protecting the United States and other American countries from the importation of p e s t i l e n t diseases from European immigrants became a later function of this organization. The Twelfth conference was concluded, after much debate, with a convention designed to replace the e x i s t i n g Sanitary Code. The general trend towards reducing the application and damaging effects of quarantine was maintained. Provisions were also made i n the convention for c o n t r o l l i n g the spread of yellow fever, although the two sanitary conferences were to remain separate. The inclusion of this disease in the European regulations demonstrates the beginning of the gradual expansion of the sanitary regulations to include diseases outside the the immediate c o n c e r n s of Europe. U n f o r t u n a t e l y , the implementation of t h i s code was delayed for eight years as a r e s u l t of World War One; i t did not a c t u a l l y come into force u n t i l 1920. THE EFFECTS OF WORLD WAR ONE ON INTERNATIONAL HEALTH COLLABORATION World War One, lasting from 1914-1918, wreaked havoc not only upon the physical and economic well-being of countries but also upon the very f a b r i c of European society i t s e l f . The d e s t r u c t i o n of s e v e r a l European c o u n t r i e s ' s o c i a l infrastructure in the aftermath of World War One was to have a 61 great influence on the development of i n t e r n a t i o n a l public health. Issues of public health had l a r g e l y been neglected during the war years, with states instead concentrating a l l t h e i r e f f o r t s on f i g h t i n g the war. As a r e s u l t of the d e t e r i o r a t i n g health and sanitary conditions, Europe, was struck with massive epidemics of influenza and typhus, which were particularly severe in the eastern sections of Poland and i n Western Russia. The seriousness of t h i s s i t u a t i o n caused the Organization International d'Hygiene Publique to r e f l e c t upon i t s essential purpose. When the OIHP resumed meetings in 1919 i t s President suggested that as a result of the war there was now a need for 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 health a f f a i r s . The idea of erecting a b a r r i e r against contagious diseases as with quarantine was declared to be s c i e n t i f i c a l l y outdated. A l l efforts were now to be directed at eliminating these epidemic diseases at their source through well developed pu b l i c health services i n a l l countries. 9 Unfortunately t h i s progressive a t t i t u d e was not to remain c h a r a c t e r i s t i c of the OIHP. Staffed l a r g e l y by seasoned veterans of e a r l i e r sanitary conferences, i t was resistant to change and new epidemiological theories. 1 0 Furthermore, the Paris O f f i c e , as p r i m a r i l y a monitoring agency, was not empowered or equipped to provide the necessary aid required to remedy the d r a s t i c s i t u a t i o n i n Eastern Europe at t h i s time. T h i s was a task f o r the I n t e r n a t i o n a l Red Cross, an organization that had been very successful in mobilizing both 62 funds and volunteers to aid the victims of the war. Af t e r the war, the League of Red Crosses believed i t should continue i t s original goal to aid humanity by combatting d i s e a s e t h r o u g h o u t the w o r l d . 1 1 T h i s c o a l i t i o n of organizations was actually the f i r s t to take steps towards the creation of a postwar i n t e r n a t i o n a l health organization. In A p r i l 1919 r e p r e s e n t a t i v e s of f i v e n a t i o n a l Red Cross organizations met to discuss the founding of an international Red Cross society that would cooperate with the League of Nations i n "a systematic e f f o r t to an t i c i p a t e , diminish and relieve the misery produced by disease and calamity." 1 2 In so doing, i t would of course cooperate with the e x i s t i n g i n t e r n a t i o n a l public health i n s t i t u t i o n , the OIHP. This cooperation was not to be as easy to 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 to safeguard and promote the peace, also created several t e c h n i c a l bodies. Included in i t s Covenant were three a r t i c l e s that deal with the matter of international health. A r t i c l e Twenty-Three stated that the League of Nations was: "to endeavour to take steps in matters of international concern for the prevention and control of disease." A r t i c l e Twenty-Five further stated that: "members of the League agree to encourage and promote the establishment and cooperation of duly authorized voluntary National Red 63 Cross associations, having as purposes the improvement of health, the prevention of disease and the mi t i g a t i o n of s u f f e r i n g throughout the world." While the League was f u l l y supportive of the Red Cross i n i t i a l l y , e s p e c i a l l y as the Treaty of Versailles did not come into force u n t i l January 1920 and current health problems needed immediate attention, i t also had i t s own a s p i r a t i o n s as an i n t e r n a t i o n a l h e a l t h organization. Included in the Covenant was A r t i c l e Twenty-Four which states that "there shall be placed under the direction of the League a l l i n t e r n a t i o n a l bureau established by general t r e a t i e s i f the p a r t i e s to such t r e a t i e s consent." 1 3 In ef f e c t , t h i s provision c a l l e d for the OIHP to be subsumed by the a c t i v i t i e s of the new international health organization of the League. This was a proposal that was to prove impossible to secure, as later events w i l l demonstrate. At f i r s t , the OIHP had given i t s assent to a merger when the League of Red Crosses Society had suggested i t i n 1919. Yet six months later this organization had clearly changed i t s mind: i t rejected the move indicating that only the original s i g n a t o r i e s of the OIHP's Rome Convention could a l t e r i t s assigned functions and purposes. While the Paris Office agreed to have t e c h n i c a l r e l a t i o n s with both the League and the International Red Cross, i t believed i t must also act to preserve i t s own independence and autonomy. 1 4 The French delegation had objected to the merger proposal at the l a s t moment. They were greatly involved in this 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 the home of the organization. It s demise might possibly r e s u l t i n a loss of prestige and influence f o r the French that they could not recapture i n the League's organization. They were supported in this view by the United States which had f a i l e d to r a t i f y the Covenant of the League and, as a r e s u l t , refused to allow the Arrangement de Rome to be rescinded and the OIHP to be absorbed into the League. Meanwhile the League of Nations had been unable to proceed with any of i t s functions. A l l of i t s e f f o r t s and energies were consumed in attempts to gain the cooperation of the Paris O f f i c e . The League of Red Cross S o c i e t i e s had grown, both i n s i z e and budget; s e v e r a l t o p - l e v e l medical s c i e n t i s t s participated in i t s a c t i v i t i e s . At this time, i t was the only effective international public health organization, publishing not only a monthly b u l l e t i n , but a l s o , the bimonthly International Journal of Public Health, both of which dealt exclusively with epidemiological reports. The deadlock between the League and. the OIHP continued unabated u n t i l June 1921 when the League proposed an ingenious solution, that was to have f a r reaching consequences on the development of future i n t e r n a t i o n a l health organizations. A "Provisional Health Committee" was to be created, consisting of fourteen individuals who were to be selected by the Council of the League on the strength of their technical qualifications, and not on the basis of t h e i r n a t i o n a l i t y . 1 5 This device 65 allowed members of the Paris O f f i c e to p a r t i c i p a t e i n the Health Organization of the League's a c t i v i t i e s . Twelve of the fourteen committee members were i n fa c t members of the Permanent Committee of the OIHP, but participated only in their personal c a p a c i t i e s . The League of Red Crosses and the International Labour Organization each also sent a delegate. T h i s committee was to c o n s u l t with the OIHP whenever circumstances required. Except for routine communications and the exchange of epidemiological information, real collaborative e f f o r t s between these two o r g a n i z a t i o n s was to remain nonexistent. An important precedent was established by the efforts of the Health Organization of the League to surmount the obstacles r e g a r d i n g c o o p e r a t i o n with the OIHP. The i n v i t a t i o n to delegates to attend the League's health conference in their own personal capacity as health experts, as opposed to being representatives of their national governments, established the p r i n c i p l e that members of i n t e r n a t i o n a l health organizations should be selected as individuals according to their s c i e n t i f i c and technical merit, a principle that remains intact in the WHO today. While the WHO i s at times p o l i t i c a l l y charged due to i d e o l o g i c a l debate, the League l a r g e l y avoided t h i s fate as a r e s u l t of t h i s compromise. The League devoted i t s e l f almost exclusively to technical issues. 1 6 This situation allowed the Soviet Union to p a r t i c i p a t e i n the International Health Committee of the League, which was v i t a l l y necessary, 66 considering the state of i t s national health, but was unlikely, considering the p o l i t i c a l tension between the Soviet Union and the rest of the members of the League. The dispute between the Health Organization of the League and the OIHP was not the f i r s t time that international p o l i t i c s had intruded upon what was supposedly an organization dedicated to p r o v i d i n g a mechanism f o r p e a c e f u l m u l t i l a t e r a l consultations between a l l nations of the world, a s s i s t i n g i n the exchange of information in technical fields, including, of course, the prevention and control of d i s e a s e . 1 7 At the i n i t i a l meetings where the Health Organization of the League was created, the French physicians declared that, while they were g r a t e f u l f o r the honour of c o o p e r a t i n g i n such a humanitarian endeavour, t h i s p a r t i c i p a t i o n could not be interpreted i n any way as suggesting that they were now prepared to take up r e l a t i o n s of any kind with the nations they had fought against i n the Great War. 1 8 The p o l i t i c a l world c o n t i n u a l l y intruded upon attempts at t e c h n i c a l cooperation. This s i t u a t i o n , despite 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 rationalize the structure of international public health, especially when the League of Red Crosses began to collapse in 1923 after the wartime enthusiasm responsible for t h e i r i n i t i a l success began to fade into the background. E f f o r t s at r a t i o n a l i z a t i o n were constantly oppossed by the OIHP. Its strongest supporter was the American 67 government, which did not want the Paris Office to be engulfed by the League, as the United States would then lose i t s foothold in international health affai r s . Other countries also opposed this merger, however: Britain refused to condone such an action u n t i l American representation was secure i n the League, and the French also objected, for reasons of prestige. A l l e f f o r t s at r e c o n c i l i a t i o n ended i n f a i l u r e ; the 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. This s i t u a t i o n was to l a s t u n t i l the conclusion of the Second World War and the formation of a unified international health orgainzation in i t s wake. The state of international public health between the two world wars was one of f l u x and change. Older h e a l t h organizations, s t i l l advocates of the ancient p r a c t i s e s i n public health, were slowly fading into the background while the Health Organization of the League, embodying the newer beliefs in international hygiene and disease control, began slowly to gain in both c r e d i b i l i t y and support. The Health Organization of the League greatly expanded i t s o r i g i n a l functions. I t created a Far Eastern Bureau located in Singapore to report on the epidemiological situation in the Far East, especially with regards to the plague. I t also took over the p u b l i c a t i o n of the "Weekly Epidemiological Report" in which facts gathered by the OIHP were distributed to members of the League. Valuable i n the c o n t r o l of dis e a s e , t h i s r e p o r t continued to be 68 published throughout the Second World War when most other functions of these two organizations were discontinued. Advances were also made in e s t a b l i s h i n g minimum acceptable standards i n f i e l d s such as n u t r i t i o n , housing and r u r a l hygiene towards which a l l nations were to strive. THE HEALTH ORGANIZATION OF THE LEAGUE ON NATIONS The League inaugurated a new form of international health cooperation with i t s Malaria Commission. I t enjoyed great success in controlling malaria's insect vector through repeated spraying of insecticides. This body was to foreshadow the new form of i n t e r n a t i o n a l t e c h n i c a l commissions that would be created under the United Nations. The object of the Malaria Commission was not only to study and advise countries on the best means of controlling malaria within their boundaries, but to i n s t i t u t e a new approach i n i n t e r n a t i o n a l health, which went beyond the cordon s a n i t a i r e approach of quarantine to combatting diseases wherever they existed by controlling their spread. 1 9 Work had also started on the standardization and u n i f i c a t i o n of various pharmacopias, which would eventually have a great influence on the pharmaceutical industries of the developed countries. A l l of these functions were to provide the foundations for the t e c h n i c a l assistance programs of the future World Health Organization. These achievements greatly differed from the approach of the OIHP, which remained firmly rooted in the epidemiological goals of the past — to keep pestilent diseases outside Europe 69 and North America, and to l i m i t restrictions on international trade and commerce. There was l i t t l e concern with taking any action to alleviate either the suffering or the causes of these diseases themselves. The an t i q u i t y of the Paris Office's mission was percieved at the time. I t did not enjoy the respect of the s c i e n t i f i c community which the League's Health Organization came increasingly to possess. The OIHP was by then considered to be l a r g e l y "a club of e l d e r l y health bureaucrats ... t h a t had been r e l u c t a n t to renounce the gastronomic and other delights of Paris". For the two interwar decades i t was viewed as the only obstacle to the r e a l i z a t i o n of the i d e a l of a si n g l e worldwide i n t e r n a t i o n a l health o r g a n i z a t i o n . 2 0 This goal was f i n a l l y achieved with the formation of the World Health Organization in 1948, which owed much of i t s heritage to precedents established by the Health Organization of the League. While the Health O r g a n i z a t i o n of the League was incr e a s i n g l y providing both advice and aid for countries to deal with their internal health care problems, the Paris Office was s t i l l concerned with the supervision and regulation of in t e r n a t i o n a l quarantine measures. For instance, i n 1924 i t oversaw an agreement signed in Brussels by fourteen countries regarding arrangements for the treatment of merchant seamen s u f f e r i n g from venereal diseases. The OIHP also made the necessary advance preparations f or International Sanitary Conferences, s t i l l l a r g e l y concerned with the regulation of 70 quarantine i n order to lessen the impediments to commercial t r a f f i c , while protecting the Western developed world from the importation of exotic diseases. These guiding principles were already well established; they now had to be applied and reinterpreted for a changing world in terms of transportation and mass travel. International commerce demanded the extention of the p r i n c i p l e s of the health regime to cover new areas of concern that had only recently arisen with modernization. THIRTEENTH INTERNATIONAL SANITARY CONFERENCE: PARIS, 1926 The Thirteenth International Sanitary Conference was convened in 1926 (the seventy-sixth year of such meetings), to debate again the v i r t u e s of land and sea quarantine. S i x t y -f i v e s t a t e s assembled i n P a r i s to c o n s i d e r whether modifications to the 1912 convention were necessary. Technical commissions studied three health problems: cholera, influenza and the control of rats in preventing the plague. In each case i t was decided that quarantine was not the most effective means of containing the spread of these diseases. States again expressed reluctance i n detaining otherwise healthy cholera c a r r i e r s . With s i m i l a r reasoning, i t was decided t h a t influenza was far too prevalent to be the subject of quarantine restrictions. Instead of the quarantine of suspected ships and their cargo, i t was determined that the destruction and control of r a t s was the best prevention for the spread of bubonic p l a g u e . Two a d d i t i o n a l d i s e a s e s were added to the international public health agenda at this time: typhus, which 71 had struck Europe in epidemic proportions following the F i r s t World War, and smallpox. 2 1 As demonstrated by these decisions, states had begun to move firmly away from the old fashioned concept of quarantine and b i l l s of health. In i t s place, international certificates were being issued to c e r t i f y the deratification and health of ships. Decisions regarding the health of ships were to be assessed on the basis of t h e i r actual condition once reaching their destination, rather than at their point of departure, as was the previous practise. Furthermore, quarantine, i f i t was to be imposed at a l l , was not to exceed the maximum l i m i t as decided by this sanitary convention. 2 2 These measures acted to reduce greatly the remaining health-related b a r r i e r s to the free flow of trade and commerce. The convention was duly signed by a l l members and remained in force u n t i l 1952 when the World Health Assembly drafted a new version. At t h i s conference p o l i t i c a l overtones once again overshadowed the spectre of international collaboration in this supposedly noncontentious area of international relations. The United States made i t expressly c l e a r when signing the f i n a l convention that t h i s act i n no way implied i t s recognition of another signatory. This move was aimed at the USSR, also a signatory, with whom the United States was not to enjoy diplomatic relations for another seven years. 2 3 Egypt also expressed i t s extreme displeasure at the continuance of the Sanitary Consul that had been established 72 the century previously to oversee maritime quarantine for the Suez Canal. This organization, administered by foreign powers, was an a f f r o n t to Egyptian sovereignty. Egypt's pu b l i c health care system, i t s delegate reported, could easily perform this task. This s i t u a t i o n was r e c t i f i e d twelve years l a t e r at the Fourteenth International Sanitary Conference in 1938, where i t was the sole item on the agenda. At t h i s same convention a clause was inserted i n the 192 6 convention which made the Permanent Committee 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 sanitary conventions. This development shows states' growing recognition on the need f o r a r b i t r a t i o n i n i n t e r p r e t i n g i n t e r n a t i o n a l h e a l t h regulations. States were s t i l l imposing excessive measures in violation of international arrangements i f they f e l t i t was in t h e i r national i n t e r e s t to have a d d i t i o n a l protection. And countries adversely affected by these actions wanted recourse to an impartial body for adjudication. This was to be one of the l a s t International Sanitary Conferences, as i t was a mode of i n t e r n a t i o n a l h e a l t h cooperation that was rapidly becoming outdated. Comprehensive sanitary arrangements had already been concluded f or most epidemic diseases, and only p e r i o d i c updating was needed to respond to new developments that affected their operation. As a r e s u l t of increasing a i r t r a v e l i t soon became obvious that the previous sanitary regulations would need to be m o d i f i e d to a d m i n i s t e r adequately t h i s new area of 73 international concern. This time a conference was not called, the documents were merely c i r c u l a t e d and i n 1935 the International Sanitary Convention for A e r i a l Navigation came into force. Agreement had been r e l a t i v e l y easy to secure for the p r i n c i p l e s of sanitary control and regulation were no longer c o n t e n t i o u s . The u n d e r l y i n g assumptions of the i n t e r n a t i o n a l sanitary regulations had been established at e a r l i e r conferences creating an international health regulatory regime. Its norms and principles were designed to ensure the maximum security against the international spread of disease with a minimum interference with world t r a f f i c . The a e r i a l convention was, i n fact, the maritime regulations of 1926 adapted to the conditions of a i r travel. Previous conventions had dealt only with the regulation of maritime quarantines, as i t had e a r l i e r been established at the Fourth International Sanitary Conference that land quarantine was both impractical and useless in preventing the spread of disease. Eventually, as international travel became more extensive, the norms of t h i s s a n i t a r y regime would be updated and si g n i f i c a n t l y changed. This process would not truly begin u n t i l a f t e r the Second World War, however, when technological developments would p r e c i p i t a t e a r e v i s i o n of h e a l t h regulations. This would not be the f i r s t , nor the l a s t , occasion these changes would have this effect upon the health regime. THE EFFECTS OF THE SECOND WORLD WAR ON INTERNATIONAL HEALTH COLLABORATION 74 With the eruption of war i n Europe yet again, the scope of i n t e r n a t i o n a l p u b l i c health returned to i t s former ro l e of epidemiological reporting and the provision of emergency aid. The Health Organization of the League continued to e x i s t throughout the war. I t s reputation was gre a t l y reduced, however, as the stature of the League of Nations d e c l i n e d . 2 4 Along with the remaining members of the OIHP, i t continued to publish the Weekly Epidemiological Report and provide as much epidemic intelligence as possible, but this became increasingly d i f f i c u l t as the war progressed. New developments, pioneered by the work of the Health Organization of the League i n areas such as nutrition 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 in order to deal with the lar g e r health problems that the war created. Although these were to be l i m i t e d ventures, they were to foreshadow the next stage of i n t e r n a t i o n a l p u b l i c health development. 2 5 In i t s short duration, the Health Organization of the League had managed to s h i f t the purpose of international health cooperation from l i m i t i n g quarantine measures and arresting the spread of disease from underdeveloped nations, to attacking these pestilent diseases themselves, 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 technical nature of the Health O r g a n i z a t i o n of the League's work. Technical e l i t e s assesed s i t u a t i o n s on the basis of medical need, rather than p o l i t i c a l orientation. For t h i s reason 75 certain a c t i v i t i e s of thes organization were highly successful. POST WAR HEALTH COLLABORATION - THE UNITED NATIONS RELIEF AND REHABILITATION ADMINISTRATION Immediate action was needed to respond to the health care emergencies World War Two created. The A l l i e d countries moved q u i c k l y to e s t a b l i s h the U n i t e d N a t i o n s R e l i e f and R e h a b i l i t a t i o n Administration (UNRRA) i n 1943. They r e c a l l e d the health d i s a s t e r s that followed i n the wake of World War One. 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 clear that a much larger organization would be needed to deal with the approximately f i f t y to seventy-five m i l l i o n people who would be medically destitute after the liberation of Europe. Health care was only a small part of UNRRA's duties, yet i t was one of i t s l e a s t c o n t r o v e r s i a l and most successful activites. I t was, at i t s time, the largest intergovernmental cooperative e f f o r t i n the f i e l d of h e a l t h 2 6 . The aim of t h i s organization was to provide f o r the l i b e r a t e d population of Europe: r e l i e f from immediate s u f f e r i n g ; food; clothing; shelter, and assistance in the return of prisioners and exiles to t h e i r homes. Also required, as a r e s u l t of such a large displacement of persons, were measures of aid in the prevention of pestilent diseases. T h i s o r g a n i z a t i o n a l s o i n s t i g a t e d epidemic c o n t r o l measures through the distribution of medical personal, supplies 76 and sprayings of DDT. This was to eliminate the typhus, malaria and yellow fever vectors. Outbreaks of cholera, plague and the more s o c i a l epidemic d i s e a s e s such as tuberculosis, influenza and venereal disease also necessitated UNRRA's attention. In addition to these functions, i n 1945 UNRRA replaced the Paris O f f i c e i n the administration and reporting of epidemiological information. UNRRA was by i t s very nature a temporary s o l u t i o n , designed to bridge the gap between the two world health organizations. In 1946 i t s funds and duties were transfered to the Interim Commission of the United Nations. This allowed the continuance of aid to countries s t i l l i n need, while avoiding the p o l i t i c a l disputes that had arisen over the adminstration of UNRRA supplies. The A l l i e d countries of the West had declared that they were not prepared to continue supplying this organization after 1946, as they believed they were receiving nothing but opposition and h o s t i l i t y in return from the recipient nations. This, no doubt, referred to their disappointment over the p o l i t i c a l orientation of the countries of Eastern Europe. This move was regarded by the USSR as proof that East and West could not cooperate. 2 7 This development was not to set a p o s i t i v e note upon which to i n i t i a t e the United Nations as the f i r s t g l o b a l peace and s o c i a l w e l f a r e organization. ORIGINS OF THE WORLD HEALTH ORGANIZATION Although international public health had been a prominent 77 aspect of the League of Nations, the need for this service was abundantly clear in the aftermath of the Second World War. This topic was i n i t i a l l y overlooked in the discussions leading up to the formation of the United Nations; i t was not u n t i l the United Nations Conference on International Organizations at San Francisco that the idea of including international health as a f i e l d of UN a c t i v i t i e s was raised. Discussion on this matter was instigated by the Chinese and Brazilian delegations. Their i n i t i a t i v e i n t h i s matter i s s i g n i f i c a n t as i t came from two developing countries, suggesting the future orientation of this organization. As time progressed this organization would come to i n c r e a s i n g l y represent the i n t e r e s t s of the developing nations, whereas previous international health institutions, on the whole, were created by the developed nations to serve their interests. A r t i c l e F i f t y - F i v e of the Charter of the United Nations recognized health as an international f i e l d for United Nations a c t i v i t i e s , w h i l e A r t i c l e F i f t y - S e v e n p r o v i d e d f o r the establishment of a specialized health agency with wide powers. A t e c h n i c a l Preparatory Committee met i n 1946 to discuss the form t h i s organization should take. At t h i s meeting the constitution of the organization was drafted and agreement was reached regarding the fate of previous existing international h e a l t h bodies. The Health O r g a n i z a t i o n of the League's functions were to be completely taken over by the new United Nations health organization, and this time the s c i e n t i f i c a l l y 78 and medically outdated Organization d'Hygiene Publique was absorbed without a struggle. Yet the formation of a single, centralized international health body was not to occur with complete ease. This time the Pan American Sanitary Bureau objected to i t s proposed takeover by the WHO. The countries of La t i n America strongly opposed t h i s measure. They wished to preserve t h e i r a b i l i t y to form a regional body, as they had been able to secure in the provision for regional collective defense under A r t i c l e Fifty-Two of the Charter of the United Nations. A compromise was reached, however, whereby the Pan American Sanitary Bureau became a regional body within the World Health Organization. The PASB continued to perform i t s t r a d i t i o n a l functions, but with the WHO remaining superior i n e s t a b l i s h i n g the general goals and objectives f o r the organization. The end r e s u l t of t h i s action was to create a highly decentralized i n t e r n a t i o n a l organization. Representation i n t h i s organization was designed to be global i n scope. A l l nations were invited to join, even those who were not members of the UN. As w e l l , w i t h i n the organization a l l members were to be equal. There were no permanent functions assigned to any specific member, although in practise those nations with the highest level of technical expertise came to y i e l d the most influence. In a manoeuvre carried over from the provisions of the Health Organization of the League, delegates were to be chosen according to t h e i r 79 t e c h n i c a l competence i n the f i e l d of health, and were not merely to represent t h e i r country, but the p r i n c i p l e s of in t e r n a t i o n a l health care i n g e n e r a l . 2 8 Further, i t was suggested that delegations come from the national health administrations of members, as opposed to the departments responsible for foreign affairs. The WHO desired technical, as opposed to p o l i t i c a l , representation, and to t h i s end established the pr a c t i s e of communicating d i r e c t l y with national health ministries. Although interference from foreign m i n i s t r i e s , by t h e i r very nature p o l i t i c a l i n orientation, could not be t o t a l l y eliminated. The fundamental differences between the World Health Organization and i t s precursors can best be found within the c o n s t i t u t i o n of the World Health Organization. A r t i c l e One states that: "the objective of t h i s organization s h a l l be the attainment by a l l peoples of the highest possible l e v e l of health". Further, i n Appendix Eight to the con s t i t u t i o n , health i s defined as: "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health i s one of the fundamental r i g h t s of every human being without d i s t i n c t i o n of race, r e l i g i o n , p o l i t i c a l b e l i e f , economic or social condition." The WHO was founded upon the idea that more was required from an i n t e r n a t i o n a l health organization than an i n t e r n a t i o n a l system of defence against common dis e a s e s . One of i t s d e c l a r e d f u n c t i o n s was to 80 strengthen the health services of member governments through programs of d i r e c t t e c h n i c a l assistance. This doctrine i s stated i n the f i r s t Annual Report of the Director General of the WHO: "the World Health Organiztion's fundamental objective i s to strengthen the health services of member goverments." It reappears later i n his third report: "WHO's third f u l l year of a c t i v i t y was characterized by the gradual, but unmistakable development of a world health consciousness and by a broadening of the general concept of the right to health." In i t s f i r s t few years, the organization was to continue with the old pattern of serving the interests of the developed s t a t e s , at the expense of those who most needed t h e i r assistance. The organization was to be further delayed from implementing i t s stated long-term goal of improving the health of a l l c i t i z e n s by the emotional appeal of a short-term s o l u t i o n to the problem of contagious diseases by i n i a t i n g a selected program of disease e r a d i c a t i o n . 2 9 Despite these occurrences, the WHO was an improvement over past international health organizations. The scope of c o l l a b o r a t i o n broadened, and a true progression i n the work of the organization can be seen developing over the years. This progression w i l l form the subject of discussion for the next chapter. 81 ENDNOTES - CHAPTER THREE 1. Norman Howard-Jones, "The S c i e n t i f i c Background of the International Sanitary Conferences" in Chronicle of the World Health Organization, (Geneva: WHO, 1975) Vol 34, p. 468. 2. A r t i c l e Four - Annex to the Rome Convention - Statutes of the Constitution of the Organization d'Hygiene Publique. 3. A r t i c l e Five - Annex to the Rome Convention. 4. Howard-Jones, "The S c i e n t i f i c Background of the International Sanitary Conferences", p. 468. 5. Ibid., p. 495. 6. Ibid., p. 497. 7. Ibid., 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 of the International Sanitary Conferences", p. 499. 10. Norman Howard-Jones, "International Public Health Between the Two World Wars", (Geneva: WHO, 1978), p. 17. 11. Ibid., P. 1. 12. Ibid., P- 13. 13 . Ibid., P- 15. 14. Ibid., P- 16. 15. Ibid., P- 29. 16. Ibid., P- 7. 17. Ibid., P- 11. 18. Norman Howard-Jones. "The World Health Organization i n H i s t o r i c a l Perspective", Perspectives i n Biology and Medicine, v o l . 24, 1981., p. 469. 19. "Evolution of International Cooperation in Public Health", Chronicle Vol 12, #7-8, p. 267. 82 20. Howard-Jones, "International Public Health Between the Two World Wars", p. 73. 21. Howard-Jones, "The S c i e n t i f i c Background of the International Sanitary Conferences", p. 501-503. 22. N e v i l l e Goodman, International Health Organizations and  Their Work, (Baltimore: The Williams and Wilkins Co., 1971) p. 73-74. 23. Howard-Jones, "The S c i e n t i f i c Background of the International Sanitary Conferences", p. 501. 24. As decided at the Fourth I n t e r n a t i o n a l S a n i t a r y Conference in Vienna, 1874. 25. C. E. A l l e n , "World Health and World P o l i t i c s " , International Organizations 4, (1950), p. 30. 26. Goodman, p. 134. 27. Ibid, p. 138. 28. Ibid, p. 147. 29. Fraser Brockington, World Health, (Edinburgh: C h u r c h i l l Livingsone, 1975), p. 177. 83 CHAPTER FOUR THE WORLD HEALTH ORGANIZATION AND THE EVOLUTION OF THE INTERNATIONAL HEALTH REGIME The problems of economic, s o c i a l and tec h n i c a l development for a l l nations have evolved i n such a way since 1945 as to make o r g a n i z e d i n t e r n a t i o n a l c o o p e r a t i o n across a l l b a r r i e r s of p o l i t i c s , ideology and culture a sheer necessity i f each of them i s to reap the benefits of the new developments i n science and technology without creating tensions and risks. Dag Hammarskjold INTRODUCTION AND EPIDEMIOLOGICAL REVIEW In 1945, the year of the formation of the World Health Organization, t r a d i t i o n a l epidemic diseases that had sparked the implementation of quarantine were receding, with other contagious diseases a r i s i n g to take t h e i r place. The l i s t of epidemic diseases of the l a s t century - cholera, the plague, and yellow fever - was revised now to include smallpox, typhus, malaria, influenza, and poliomyelitis. The control of the more social diseases such as tuberculosis and venereal diesases was now pursued by the Western nations. 1 As previous methods of disease containment had not proven e f f e c t i v e i n preventing epidemic invasions, i t was decided to embark upon a new course of action, a s e l e c t p o l i c y of eradication, to eliminate the epidemic f o c i of c e r t a i n diseases at 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 to embark upon such a campaign. Instead, attempts were made 84 only to contain disease. Quarantine had been used as a means of protecting the developed European countries from the spread of Asian disease. Yet these measures had not only proved i n e f f e c t i v e i n achieving t h e i r goal, they also came under i n c r e a s i n g c r i t i c i s m f o r t h e i r d e t r i m e n t a l e f f e c t s on international trade. With the e s t a b l i s h m e n t of i n t e r n a t i o n a l h e a l t h organizations at the turn of the century, attempts were made to move beyond a purely defensive response. I t had by t h i s time been s c i e n t i f i c a l l y confirmed that the best method to control the spread of epidemic disease was to develop a country's p u b l i c health f a c i l i t i e s , thereby increasing i t s i n t e r n a l resistence to disease. For t h i s s o l u t i o n to be enacted both t e c h n i c a l and f i n a n c i a l aid was needed for the developing countries, which more often than not was where the spread of these d i s e a s e s had o r i g i n a t e d . They l a c k e d the b a s i c resources to implement such a program on t h e i r own. The Health Organization of the League of Nations had attempted to reor i e n t public i n t e r n a t i o n a l health i n t h i s d i r e c t i o n by i n i t i a t i n g studies that determined guidelines f o r minimum standards of hygiene, nutrution, and sanitation services. This organization, unfortunately, lacked the resources and p o l i t i c a l power to put any of t h e i r studies' conclusions into general practice. Despite the p r o g r e s s i v e nature of the World Health Organization's stated goals to promote the welfare of a l l 85 c i t i z e n s through the strengthening of the health services of member states, 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 was to progress only slowly from i t s former concern with defense against the spread of disease toward the establishment of these newer ideals. Although the WHO embraced the idea that more was required of an i n t e r n a t i o n a l health organization than an i n t e r n a t i o n a l system of defense against common disease, the i n i t i a l actions of i t s Interim Commission were very much a continuation of the traditional work of previous international health organizations. These duties centered primarly on epidemiological reporting and providing emergency aid for outbreaks of contagious disease when they threatened the interests of the more developed nations. For instance, during i t s b r i e f h i s t o r y , cholera had again broken out i n Egypt and immediate action was needed to contain i t s spread before i t reached the Mecca pilgrimages. The Mecca pilgrimages were again a source of i n t e r n a t i o n a l concern and action because of t h e i r p o t e n t i a l to spread disease normally epidemic only i n Asia to the uninfected West. During i t s two year tenure the Interim Commission of the World Health Organization was not concerned with eradicating contagious diseases at their source, only with containing their spread to uninfected areas. This action was again required when Italy and Greece, in their weakened condition, succumbed to an extensive attack of malaria. They received quick a t t e n t i o n from the Commission, even though the m a l a r i a 86 i n f e s t a t i o n i n these two Western developed countries was not nearly as severe as i t was i n many of the l e s s e r developed members of the WHO. This point especially demonstrates the stro n g c o n t i n u i t y between the WHO and pr e v i o u s h e a l t h organizations. For the f i r s t few years the programs of t h i s organization continued to center on providing emergency r e l i e f and protective regulation to the developed countries. PROGRAMS OF DISEASE ERADICATION It was not u n t i l i t s second decade that the WHO was to embark upon a program of disease eradication. I t f i r s t singled out malaria at the Eighth World Health Assembly and l a t e r embarked upon an international effort to eliminate the scourge of smallpox at the Eleventh Assembly. The f i r s t of these e f f o r t s was an abysmal f a i l u r e ; the second was to prove eventually a complete success. The reasons for one program's effectiveness and the other's failure are very much related to the s c i e n t i f i c natures of the two diseases. Malaria i s spread from person to person, through an intermediate agent, the mosquito. As there i s no vaccine f o r malaria, repeated spraying of i n s e c t i c i d e i s necessary to destroy the insect vector. Few of the l e s s e r developed nations possessed the medical, technical, or financial resources to guard constantly against a reoccurrence of t h i s disease. As well, s o c i a l customs, such as nomadic migrations and the seclusion of women greatly increased the d i f f i c u l t i e s involved in disease control. A further d i f f i c u l t y was posed by the tendency of mosquitoes 87 to become r e s i s t a n t to i n s e c t i c i d e s , which i n any case were only effective for a short duration. What was most damaging to t h i s campaign, however, was the complacency that developed a f t e r the i n i t i a l outbreak was under control and contained. Constant vigilence i s required to prevent a reoccurrence of the disease i n epidemic form. Yet a s u b s t a n t i a l portion of the countries where the disease was endemic were reluctant to accept the implications of t h i s epidemiological fac t and preferred, instead, to devote resources elswhere. Smallpox, i n comparison to malaria, was a much easier eradication program to implement. A p r o t e c t i v e vaccine had been i n existence since 1798. What was needed was a system and program of global innoculation. The vaccine needed to be strengthened and improved f i r s t , however, so i t could withstand long storage times i n hot climates. A s p e c i a l bifurcated needle was also developed under the auspicies of the WHO's technical research programme on smallpox eradication and this g r e a t l y improved the e f f i c i e n c y of vaccination. I t had been demonstrated that eradication from an endemic area can be realized when eighty percent of the population i s successfully vaccinated within a time period of f i v e years. This i s c o n s i d e r a b l y e a s i e r to achieve than what appears to be necessary to eliminate malaria. The World Health O r g a n i z a t i o n was c e n t r a l to the development of these programmes, providing both technical assistance and medical personal to countries that lacked 88 adequate resources of their own. A central body was needed to coordinate the planning for these campaigns, f o r p o l i t i c a l boundaries are i l l o g i c a l parameters within which to conduct an eradication program. It proved to be quite easy to secure the necessary approval of states for these programs, as the costs of eradication were often less than the economic cost that the diseases themselves enacted i n terms of losses to the labour force. For instance, according to a WHO sponsored study, "malaria i s the most expensive disease in the world; i t stunts the p h y s i c a l and mental growth of persons, hampers the community i n exploration of national resources, reduces agricultural production and impairs industry and commerce."3 In the developed countries these p e s t i l e n t diseases no longer posed a substantial health risk. Most were eradicated and, i f an outbreak did suddenly occur within these countries, i t could be quickly contained by t h e i r well-developed health care systems and resources. And yet the developed countries were supportive of these eradication programs. One explanation as to why i s the emotional appeal of eradication programs. It was very much i n the s p i r i t of the United Nations to embark upon such a worthwhile humanitarian venture. Supporting such a proposal would only enhance a developed country's international standing with the newly independent members of the WHO. This no doubt was one of the motivating factors behind the Soviet Union's proposal for a global eradication program for smallpox. Moreover, the degree of i n t e r n a t i o n a l t r a v e l had also 89 undergone a great expansion. Developed nations required travel to be safe from the spectre of i n f e c t i o u s diseases, as well as to be f a s t and e f f i c i e n t and f r e e from the delays of quarantine. International t r a f f i c i s one of the foundations of modern economic development. E f f i c i e n t trade requires the control of epidemic diseases and the e l i m i n a t i o n of lengthy quarantine periods. Tourism was also an area of growing economic importance to many countries. This industry could be grea t l y damaged by an outbreak of a contagious disease. Further, with the growing interdependence of the world's economies and the emergence of multinational firms, operating on a global scale, disease control was c l e a r l y desirable. I t was desired by the developing country, hoping to attract such a firm, and by the multinational i t s e l f , needing a healthy workforce and not w i l l i n g to expose i t s own employees to possible unhealthy situations. THE INTERNATIONAL HEALTH REGULATORY REGIME -THE ISSUE OF SANITARY REGULATIONS The old methods of disease containment, quarantine and b i l l s of health, were increasingly proving to be ineffective as well 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 revise and amalgamate a l l of the previous sanitary conventions, even though they had not proven to be very e f f e c t i v e i n t h e i r stated goals of ensuring the maximum security against the international spread of disease, with a minimum amount of interference with world t r a f f i c . 4 The recently updated version of the sanitary 90 regulations, ori g i n a l l y implemented in 1952, did not prevent an outbreak of cholera in Asia and the Middle East in 1961. There were also constant instances of noncompliance with the sanitary regulations that not only damaged any effectiveness they might have had, but increasingly brought the c r e d i b i l i t y of these regulations into disrepute. The 1952 e d i t i o n of the sanitary regulations contained several new provisions that were a significant improvement over ea r l i e r versions. Recognizing that one of the most troublesome aspects of e a r l i e r conventions was securing their r a t i f i c a t i o n , the new e d i t i o n of the s a n i t a r y code had abandoned the t r a d i t i o n a l t reaty form. Instead, upon becoming a member of the WHO under A r t i c l e 22 of i t s Constitution, the sanitary regulations were to come into immediate effect, unless a state n o t i f i e d the Health Assembly w i t h i n nine months of i t s reservations regarding certain Articles. This process, termed "contracting out", was suggested by the American delegation and was agreed to by the Interim Commission a f t e r a b r i e f debate regarding i t s implications for state sovereignty. In the end i t was decided that as these regulations governed only highly t e c h n i c a l issues they would not endanger the power of the nation state in a significant fashion. The WHO was also given, under A r t i c l e 21 of the Sanitary Regulations, wide authority to draw up regulations on any new health issue that might arise. To date i t has not excercised t h i s option. 5 "Footnotes" are used instead as a d d i t i o n a l 91 recommendations added on to p r o v i s i o n s i n the s a n i t a r y regulations that permit the organization either to interpret or amplify specific components of the regulations. The option to use this procedure to implement policy changes, as opposed to the more formal 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 to preserve a noncontentious r o l e i n matters of international health. I f a state has objections to p a r t i c u l a r regulations, i t can choose to adopt the regulations with reservations against s p e c i f i c a r t i c l e s . The assumption behind t h i s p r o v i s i o n i s that by allowing states to opt out of p a r t i c u l a r regulations f o r s p e c i f i c reasons i t w i l l encourage more widespread compliance of them o v e r a l l . 6 There i s , however, a three year time l i m i t on reservations and they must be approved by the World Health Assembly. This prevents the emasculation of the regulations and ensures that reservations do not i n fac t constitute an actual rejection of the sanitary regulations. A r t i c l e 99 of the Sanitary Regulations also allows for states to adopt, under "special arrangement", health measures i n addition to those prescribed i n the sanitary code. The underlying purpose of t h i s p rovision i s to f a c i l i t a t e the eventual a p p l i c a t i o n of the sanitary code i n i t s o r i g i n a l and complete form.7 Special arrangements are to be u t i l i z e d when a p a r t i c u l a r health s i t u a t i o n warrants them. For instance, countries that consider themselves to be at great risk because of their lack of public health f a c i l i t i e s can impose sanitary 92 provisions in excess of the regulations to protect themselves from a contagious disease that has not yet infected t h e i r population. In such a case, a s p e c i a l arrangement can be i n the best i n t e r e s t s of i n t e r n a t i o n a l public health. Again, as w i t h r e s e r v a t i o n s , s p e c i a l arrangements are l i m i t e d to interpretation 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 prohibitive. Reservations have proven very useful over the years when u t i l i z e d by states who agree with the regulations in principle, but, for unforseen circumstances, are unable to comply with them. Ethiopia established 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 notify 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 principles of the sanitary code.8 The advantages of contracting out are obvious. It allows the quick submission and approval of the highly technical i n t e r n a t i o n a l sanitary agreements, as well as f l e x i b i l i t y i n updating these regulations to meet current situations. 9 Over the years there has even been a drop i n the number of reservations, as states are increasingly able to adhere to the norms of the sanitary code in greater detail. 1 0 The norms of the h e a l t h regime are not, however, synonymous with the s t a t e d goals of the World Health Organization. The norms of this regime are s t i l l based largely on p r i n c i p l e s established during the sanitary conferences. 93 This regime had undergone a period of t r a n s i t i o n , with the formation of international health organizations. The degree of this evolution can be seen in the general principles that were drawn up to guide the drafting of the new sanitary regulations: 1. Accurate and rapid notification are the basis of effective measures against the international spread of disease and t h e r e should be a withdrawal of 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 t r a f f i c as soon as the danger of i n f e c t i o n i s passed. 2 . Each country should develop i t s i n t e r n a l resistance to disease rather than rely on measures taken at frontiers. 3. Measures taken at f r o n t i e r s should be the minimum compatible with the existing sanitary situation. Excessive measures not only exert undue interference with t r a f f i c and have severe economic consequences, but by t h e i r very excess might lead to deliberate evasion of the sanitary code and thereby defeat the original object. While these principles show the continued presence of the norms of the e a r l i e r health regime, the prevention of the spread of disease with a minimum amount of interference with i n t e r n a t i o n a l t r a f f i c , they also codify two new concepts i n i n t e r n a t i o n a l health protection o r i g i n a t i n g from the work of e a r l i e r international health organizations. The f i r s t i s the value of epidemiological notification in containing the spread of disease; the second i s the value of increasing a country's internal resistance to combat disease i t s e l f . 94 To further the f i r s t of the above principles, a l l members were required to transmit accurate and rapid n o t i f i c a t i o n on any outbreaks of s p e c i f i c diseases. At the formation of the WHO these included yellow fever, cholera, plague, and smallpox. This l i s t was a reduction in the number of diseases covered by the previous agreement of 1926. The second p r i n c i p l e advocating countries develop t h e i r own internal resistence to disease forms the j u s t i f i c a t i o n for the many te c h n i c a l and d i r e c t assistance programs. This 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 technical e l i t e s , who put this policy into practice. It was also significant as the adoption of t h i s p o l i c y i s a further demonstration of the abandonment of quarantine as a public health measure. The t h i r d p r i n c i p l e reasserts the norms of the e a r l i e r health regime by stressing that the health measures contained in the regulations are the maximum allowable. Under the WHO, i t was s t i l l an important component of the regime to preserve the free flow of international trade. The regulations themselves were l a r g e l y concerned with halting the spread of disease through the provision at airports and ports of proper medical f a c i l i t i e s to t r e a t communicable diseases. The sanitary regulations constituted the maximum procedures allowable in terms of demanding health certificates and imposing quarantines, anything above these provisions i s deemed to be an "excessive measure" and i s subject to review by 95 the organization. The WHO assumes that the sanitary provisions contained i n i t s regulations w i l l be e f f e c t i v e i n countering the spread of disease, and that along with a regular flow of 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 these communicable diseases, they w i l l discourage the deployment of excessive measures. The regulations can be viewed as part of an evolutionary process. B i l l s of health were f i n a l l y abolished and the process of contracting out made the adoption of regulations and their subsequent r a t i f i c a t i o n much ea s i e r . 1 1 This enabled more states than ever before to become signatories to t h i s set of s a n i t a r y r e g u l a t i o n s . For the f i r s t time the s a n i t a r y regulations were in complete harmony with modern public health and epidemiological theories. Quarantine had been replaced by a system of epidemiological intelligence and notification. NON-COMPLIANCE AND THE SANITARY REGULATIONS Despite these evolutionary advances in the 1951 sanitary code, states continued to v i o l a t e these regulations for a myriad of reasons. Some states were not able to implement the regulations, lacking the adequate t e c h n i c a l resources, while others preferred their own solutions to the ones suggested in the s a n i t a r y code. There are two p a r t i c u l a r areas of noncompliance: n o t i f i c a t i o n of an outbreak of reportable diseases and the imposition of excessive measures. The extent of noncompliance has been extensive in certain areas, enough to question the f e a s i b i l i t y of the health regime i t s e l f . The 96 successful functioning of the health regime i s based, in part, on states notifying the organization of outbreaks of contagious diseases. Aid and technical resources can then be concentrated i n t h i s area to enact a rapid s o l u t i o n to the problem. If states f a i l to notify, the spread of disease can grow and this, i n turn, prompts states to impose extra measures to protect themselves from an a p p a r e n t l y u n c o n t r o l l a b l e epidemic. I r o n i c a l l y , f a i l u r e to n o t i f y the outbreak of a p a r t i c u l a r disease i s often motivated by fear of the imposition of e x c e s s i v e measures. I t appears to be i n a state's best i n t e r e s t both to comply and not to comply with the sanitary regulations. To comply with them allows for quick action and promotes confidence in the regime, but also entails the risk of other states imposing excessive measures against their trade or nationals. The a p p l i c a t i o n of sanitary regulations for a nation state i s balanced against i t s economic and administrative concerns. Reporting the outbreak of a n o t i f i a b l e disease i s regarded by many developing countries as the mark of a Third World country and e n t a i l s a l o s s of prestige. Admitting the existence of one of these p e s t i l e n t diseases can also greatly harm the tourist industry of a country, which often constitutes a large percentage of a developing country's revenue. 1 2 The WHO i s v i r t u a l l y powerless to stop these violations; as an i n t e r n a t i o n a l organization i t has no power to force the compliance of states regarding i t s regulations. The most i t 97 can do i s publish the v i o l a t i o n s to bring the pressure of the i n t e r n a t i o n a l system upon a state i n an e f f o r t to force i t s compliance. There are very s t r i c t regulations as to what epidemiological information can be transmitted. Under A r t i c l e Eleven of the Sanitary Regulations, the WHO may only publish information from authorized sources; the national health m i n i s t r i e s of members.13 Even when the organization has confirmed information of the existence of a notifiable disease from other re l i a b l e sources, such as a medical delegation from another country, i t i s r e l u c t a n t to act f o r f e a r of antagonizing a member. The WHO prefers to keep correspondence at the level of national health ministries; accusing a country of violating the sanitary regulations would undoubtedly bring the more p o l i t i c a l foreign m i n i s t r i e s into the dispute. The organization f e e l s i t i s counterproductive to p u b l i c i z e noncompliance. When i t receives information from other sources, i t attempts to persuade the country i n v i o l a t i o n to notify on i t s own accord. 1 5 In a p a r t i c a l a r case where the respect of the Director-General was high, the WHO has reported the existence of a notifiable disease, despite that country's fa i l u r e to admit the existence of t h i s s i t u a t i o n . During the 1970 outbreak of cholera i n the sub-Sahara region of A f r i c a , Guinea refused to n o t i f y the outbreak of t h i s disease. Not only was t h i s outbreak particularly severe, i t was also the f i r s t outbreak of t h i s highly susceptible region i n a number of years. After 98 repeated requests by the Director General to report the existence of t h i s disease, 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 far, been the only instance where the organization had reported the existence of a disease against the wishes of a member state. In t h i s case, several unique conditions were present. F i r s t , there was serious concern over the p o s s i b i l i t y of a new outbreak of cholera in a uninfected population with poor medical services. Second, repeated e f f o r t s to have the offending country n o t i f y the organization of i t s true status were met with silence. And t h i r d , the Director General at t h i s time, Dr. M. G. Candau, enjoyed great respect and authority within the organization. 1 6 This developement i s a further sign of the evolution ofthe international health regime. Where once o f f i c i a l s would only have acted with the d i r e c t authority of member states, they acted i n t h i s instance upon t h e i r own authority, usurping the traditional power of the nation state to a degree. The World Health Organization recognizes that i n many cases noncompliance i s not due to intransigence on the part of a member, but the lack of adequate resources i n terms of equipment and personnel to comply with the s a n i t a r y r e g u l a t i o n s . 1 7 Many of the h e a l t h problems t h a t the regulations r e f e r to, such as the containment of contagious diseases, cannot be solved by mere regulation alone. The World Health Organization appreciates that the health problems the 99 developing states face are outside the scope of regulation. What i s needed instead i s improvements in basic health care and sanitation services. Another reason behind the fai l u r e of states to inform the WHO of an outbreak of a n o t i f i a b l e disease i s t h e i r fear of excessive measures that other states might unjustifialby place upon their trade or travelling nationals. In many cases states have reason to worry over the possible imposition of these measures as they had occurred i n the past with some degree of frequency. For instance, in 1966 Iraq duly notified the WHO of an outbreak of cholera. Surrounding countries immediately imposed extra r e s t r a i n t s on t r a f f i c from Iraq. Despite repeated appeals from the WHO, these nations refused to respond to these charges or to remove the excessive measures. Four years later a similar situation arose with regards to Israel, which had also notified the WHO of a cholera outbreak. As a r e s u l t of the u n f a i r i m p o s i t i o n of e x c e s s i v e measures, countries have taken to minimizing the appearance of an outbreak i n order to avoid possible r e t a l i a t o r y measures. Information regarding the status of n o t i f i a b l e diseases submitted to the WHO has often been imcomplete, inadequate, or has only reported a minimum number of cases. As well, states would prematurely announce that they were free of disease in an effort to avoid the damaging effects of excessive measures. 1 8 The WHO often had information from other re l i a b l e sources that contradicted the information that a member reported. Yet 100 again, under A r t i c l e Eleven of the Regaulations, i t was powerless to issue any of t h i s a l t e r n a t i v e information. The organization also understood the predicament many of these in f e c t e d states were i n and did not want further to alienate them by challenging the v a l i d i t y of their information. In most cases excessive measures were i r r a t i o n a l responses on the part of states, who greatly feared an outbreak of one of these p e s t i l e n t diseases. As with quarantine i n the past, e x c e s s i v e measures r e a s s u r e d s t a t e s by p r o v i d i n g a psychological barrier against an infectious disease that could i n f l i c t great harm upon them. Yet excessive measures were not the best means of protection against these pestilent diseases; instead states needed to promote the i n t e r n a l development of good pu b l i c health and s a n i t a t i o n f a c i l i t e s . The countries that most often u t i l i z e d excessive measures were the ones with l e s s advanced public health care systems and therefore f e l t themselves to be at greater risk. The WHO was v i r t u a l l y powerless to stop these infractions, despite the fact that their continued use, greatly weakened the c r e d i b i l i t y of t h i s organization and the health regime. The WHO published the imposition of excessive measures i n the Weekly Epidemiological Report in an attempt to discourage their u t i l i z a t i o n and offered to use i t s "good o f f i c e s " to t r y and s e t t l e disputes that arose over these measures. This i s o f f i c i a l l y provided for under A r t i c l e 106 of the Sanitary Regulations, although the matter i s usually dealt with under 101 less formal conditions. The overwhelming majority of disputes are handled at the technical level, 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, for a more formalized method of s e t t l i n g disputes: "any such dispute which has not been thus settled (through the use of WHO'S good offices), may by national application, be referred by any state 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 provision has only been u t i l i z e d once, in 1970 with an incident i n v o l v i n g Turkey, Romania, and Bulgaria. As a r e s u l t of the cholera epidemic of the 1960s many countries sought to impose severe f r o n t i e r r e s t r i c t i o n s on persons and goods from neighbouring countries suspected of harbouring cholera, despite the f a c t that t h i s was prohibited i n the regulations. While most of the countries that faced t h i s s i t u a t i o n appealed to WHO'S good o f f i c e s , Turkey invoked A r t i c l e 106 of the Regulations. I t complained that Bulgaria and Romania had closed t h e i r f r o n t i e r s to Turkish convoys of food produce and were requiring vaccination c e r t i f i c a t e s from their nationals, despite that fact that Turkey had been declared infected. The measures were not permitted under the Sanitary Regulations. This matter was quickly s e t t l e d a f t e r i t was brought to the o f f i c i a l l e v e l , where the more p o l i t i c a l departments of governments, the foreign a f f a i r s bureaus, became involved. The offending countries withdrew the objectionable measures to avoid 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 resolution of the dispute i t has not been employed since, no doubt reflecting the desire of health ministries to keep health disputes at a technical level, avoiding the more p o l i t i c a l solutions. The reappearance of cholera in epidemic form in the 1960s i n A f r i c a and Asia had a f a r reaching e f f e c t upon the health regime; i t caused a serious revaluation of the aims and methods of t h i s organization. Widespread noncompliance with the sanitary regulations, the fa i l u r e of states to notify outbreaks of cholera, as well as the prevalent use of excessive meaures had combined to create a serious problem of c r e d i b i l i t y for t h i s regime. F a i l u r e s to n o t i f y outbreaks of cholera were so predominant that they l e d to discussions of i t being removed from the l i s t of notifiable diseases. It was decided, however, that this measure would only exacerbate the situation, and as the requirement to notify encouraged some degree of compliance i t should remain. 2 1 The eradication campaign for malaria had also experienced substantial setbacks. Several states that had entered the "maintenance" or "consolidation" phases of the programme, where they were declared free or nearly free of the disease, suddenly experienced major outbreaks. 2 2 In li g h t of these developments the Twentieth World Health Assembly recommended a reexamination of the e n t i r e strategy. I t was gradually realized that eradication programmes were doomed to fa i l u r e — the countries of the developing world did not posses the resources to s u c c e s s f u l l y carry out such a task, and the 103 developed countries are unwilling to contribute these resources to them. EVOLUTION WITHIN THE WORLD HEALTH ORGANIZATION Advances in the two eradication programs had occurred when states concentrated t h e i r resources i n health care. Once r e s u l t s were achieved t h e i r attention to t h i s area weakened however, and setbacks occurred. 2 3 These incidents and the general f a i l u r e of the sanitary regulations to generate the compliance of states and control the spread of disease was to lead to major innovations 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 that i n the near f u t u r e e r a d i c a t i o n was i m p o s s i b l e f o r the m a j o r i t y of contagious diseases. As such, i t was decided to embark upon a policy of "epidemiological surveillance". Recognizing that the importation of epidemic diseases could not be halted i t was decided to concentrate resources on n o t i f y i n g , assessing, coordinating, and controlling a l l communicable diseases, both at the national and at the i n t e r n a t i o n a l l e v e l . I t was hoped through t h i s process that early containment of disease would become progressively more plausible; successful disease control was to be achieved through a t t r i t i o n , rather than by a d i r e c t a s s u l t . 2 4 This p o l i c y was inaugerated at the t w e n t y - f i r s t World Health Assembly and resulted i n a r e v i s i o n of the Sanitary Regulations. Changes i n the 1971 e d i t i o n of the regulations included 104 the absorption of the International Quarantine Bureau by the G l o b a l E p i d e m i o l o g i c a l S u r v e i l l a n c e Bureau. The name "International Sanitary Regulations" was also changed to "International Health Regulations." The term "quarantinable disease" was dropped and the number of diseases subject to regulation was reduced to four, as typhus was no longer considered a serious health hazard. More significantly, these changes are a development away from the narrow, l e g a l i s t i c "sanitary p o l i c i n g " method of disease c o n t r o l to a more cooperative approach. The 1970s was to witness a major evolution in the orientation of the World Health Organization and the International Health Regime. It had been realized that regulations had not been e f f e c t i v e i n eradicating or even controlling the spread of disease i n the past. Thus, a growing trend i n the WHO was to employ reccommendations instead of regulations. In fact, there has not been a new regulation for f i f t e e n y e a r s . 2 5 I t had been learned that the best 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. The World Health Assembly had recognized that regulations were of no use unless states possessed the c a p a b i l i t y i n terms of f i n a n c i a l and health resources. In order for t h i s to occur, there had to be a change i n the p o l i c i e s of the organization. The o r i g i n s of t h i s p o s i t i o n can be seen i n the r e a l i z a t i o n of the l i m i t a t i o n s of the former s t r a t e g i e s of 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 provide d i r e c t t e c h n i c a l assistance to i t s member states. This position was to only slowly gain support within the organization; but by 1975 and the conference on Primary Health Care at Alma Ata, i t was firmly in place. The explanation for the evolution i n the o r i e n t a t i o n of the WHO i s two-fold. In the f i r s t instance the WHO was subject to the same pressures as the United Nations was as a result of decolonization. A large influx of developing nations entered the o r g a n i z a t i o n , most l a c k i n g adequate p u b l i c h e a l t h f a c i l i t i e s . The regulative aspects of the organization did not i n t e r e s t these states to a large extent as they did not have sub s t a n t i a l trade i n t e r e s t s that would be hampered by the imposition of excessive measures. While epidemioligcal surveillance no doubt provided them with some benefits, these countries had never known a period without a serious epidemic. A r r e s t i n g the spread of a s i n g l e disease would not cause a substantial increase in the health of their populations. What was needed was the provision 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 , as well as slowing the spread of disease. This change i n o r i e n t a t i o n was not well received by the members of the developed s t a t e s . T h e i r goals f o r the organization differed dramatically from those of the developing states. Their interest in the health regime was to control the spread of pestilent diseases from the less developed countries, while l i m i t i n g the restrictions placed upon international trade 106 and travel, the sampe principles they supported at the sanitary conferences. While the e r a d i c a t i o n of d i s e a s e and the reduction of i t s scope was c l e a r l y i n the i n t e r e s t s of internationl travel and had a certain emotional appeal for the developed s t a t e s , they were not w i l l i n g to f i n a n c e the development of the Third World's health infrastructure. While the members of the Executive Board of the WHO, were not a l l pleased with the direction the organization was taking with the increasingly vocal pronouncements of the developing states, they came as the policy-making body of the organization to accept the v a l i d i t y contained in some of these demands. It was realized by several members of the Executive Board that a change i n policy was necessary as they were genuinely committed to the i d e a l s expressed i n the o r i g i n a l goals of t h i s organization. Despite the objections on the part of certain states and a few members of the Executive Board, the WHO launched this new program in the mid-1970s. The beginnings of this new stage in i n t e r n a t i o n a l health care can be seen by the s e l e c t i o n of a new Director-General, Dr. H. Mahler replacing Dr. M. G. Candau, who had held t h i s o f f i c e for over twenty years. The new Director General had a d i s t i n c t v i s i o n for the organization, which he was determined to see f u l f i l l e d . During i t s f i r s t twenty-years the WHO was p r i m a r i l y a m u l t i l a t e r a l i n s t i t u t i o n , concerned l a r g e l y with campaigns against s p e c i f i c diseases, following largely the lead of the developed countries who set i t s agenda. 107 Accordingly, the development of systematic health care was the responsibility and concern of member states. The United States who, because of i t s technical expertise and significant budget contribution, 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 limited to the problems of public health and preventative medicine. The U.S. did not want the organization to become involved in any way in the area of socialized medicine. 2 7 As a large number of states from the Third World joined the organization, however, i t became inc r e a s i n g l y accepted by the executive board that the WHO should provide assistance i n strengthening the health services of member states. 2 8 This movement within the organization was linked to the c a l l s f o r a New International Economic Order i n the General Assembly of the United Nations. In h i s 1976 Annual Report to the World Health Assembly, Mahler embraced this movement and r e f e r r e d to i t s appeal to the WHO, "to i n t e n s i f y the international effort aimed at improving basic health conditions i n developing countries . . . p r i m a r i l y to the prevention of diseases and malnutrition by providing primary health services to the communities, including maternal and ch i l d health as well as family w e l f a r e . " 2 9 Mahler went on to suggest that the General Assembly had vindicated the stance the WHO had already embraced, having learned from i t s mixed experience with disease eradication the need to b u i l d up l o c a l health services by improving the s o c i a l and economic systems of the developing 108 countries. u The New International Health Order was to be implemented by providing what was termed "primary health care" to a l l c i t i z e n s of the world. The plan of action f o r implementing this program was termed "Health for A l l by the Year 2000". The goals of t h i s program were quite ambitious; they c a l l e d for a global m o b i l i z a t i o n of health resources, whereby the main target of governments i n cooperation with the WHO was the attainment of the highest level of health for every individual, which would allow them to lead a s o c i a l l y and economically productive l i f e . 3 1 The WHO wants to ensure by the turn of the century that: a l l people have access to essential health care and r e f e r r a l f a c i l i t i e s ; a l l governments w i l l have assumed o v e r a l l health r e s p o n s i b i l i t y for t h e i r people; everyone had access to safe drinking 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 children w i l l be immunized against the major i n f e c t i o u s diseases; control w i l l e x i s t of the major communicable diseases; and, f i n a l l y , essential drugs w i l l be a v i a l a b l e to a l l . 3 2 The aim of the program i s to provide health care at the local level, and i t was designed to be adapted by each country to meet t h e i r s p e c i f i c needs. The WHO had r e a l i z e d t h a t i n the past i t was g u i l t y of not providing the most appropriate health care advice to the developing countries; universal models, based l a r g e l y on the experiences of the developed c o u n t r i e s were doomed to f a i l u r e . 3 3 109 This movement can be interpreted as a return to the ideals contained i n the c o n s t i t u t i o n of the WHO that: health i s a state of complete physical, mental, and social well-being and not merely the absence of disease or i n f i r m i t y , and the enjoyment of the highest attainable standard of health i s one of the fundemental r i g h t s of every human b e i n g . 3 4 The reason behind the renewed i n t e r e s t i n these aims was the growing conviction that health care was a fundamental social right, and the beli e f that national governments shall be responsible for c r e a t i n g the c o n d i t i o n s f o r i t s implementation. These p r i n c i p l e s have gradually become a norm fo r most of the i n d u s t r a l i z e d states and were eventually t r a n s f e r r e d to the international l e v e l . 3 5 Despite the high ideals of this program i t has not been a t o t a l success i n terms of i t s implementation. When Mahler stated that i t was regrettable that members, "spend three quarters of the health budget on highly sophisticated, disease-oriented i n s t i t u t i o n a l care of individual patients in capital c i t i e s - leaving large parts of the c i t i e s without primary h e a l t h care", he a l s o d e c l a r e d , "that by 1980 the organization should be restructured so that s i x t y percent of i t s regular budget was allocated to technical cooperation, and the provison of services to member states." 3 6 This meant that the administrative budgets of the regional o f f i c e s would be reduced with a corresponding reduction in staff. This had not been w e l l r e c e i v e d by some members of the world h e a l t h 110 bureacracy who have f a i l e d to implement t h i s program to the best of t h e i r a b i l i t i e s . They have grown too fond of the benefits that working f o r an i n t e r n a t i o n a l organization can provide. 3 7 O b j e c t i o n s have a l s o been r a i s e d by s e v e r a l of the developed states as the "Health for A l l Program" has brought this organization into c o n f l i c t with the interests of business and the larger multinational corporations of the world. 3 8 The WHO has become increasingly active i n t h i s area i n the l a t e 1970s. I t s e n t i r e involvement i n the development of a marketing code for breast milk substitutes raised great concern amongst the multinational corporations. The pharmaceutical industry fears that i t w i l l be the next target of WHO sponsored interference. For t h i s organization has frequently made statements regarding the s u b s t a n t i a l drain of resources pharmaceutical products are for developing countries, and how the drugs supplied are, to a great degree, inadequate f o r the needs of these countries. The WHO has already proposed they be standardized and regulated to ensure a f a i r d i s t r i b u t i o n throughout the world. The WHO has also incurred the wrath of the tobacco firms. It has increasingly condemned smoking as a health r i s k and i n i t i a t e d a worldwide campaign against i t , to improve the overall general level of health. These recent forays of the Organization have brought i t into c o n f l i c t with the more developed states who represent the i n t e r e s t s of the multinationals. The United States, in particular, has had the I l l strongest reaction to this change in the agenda of the WHO. It was the only country to vote against the Marketing Code for breast milk substitutes and has e s p e c i a l l y under the Reagan administration accused the WHO of catering to "Third World Marxist ideologues". I t has expressed i t s displeasure with the o r g a n i z a t i o n by i n c r e a s i n g l y reducing i t s budget contribution; to date i t has paid $10,000,000 of i t s assessed $62,000,000 dues this year (1987). This action has placed the organization 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 to force the WHO to return to p o s i t i o n s that are more compatible with U.S. business i n t e r e s t s . 3 9 CONCLUSIONS - WHY THE EVOLUTION ? While t h i s c o n f l i c t with the developed states had been r e f l e c t e d to some degree i n the World Health Organization's General Assembly, i t has not i n fac t permeated the top l e v e l of t h i s organization, the Executive Board. These i n d i v i d u a l s remain committed to the goals of "Health f o r A l l by the Year 2000" Program. This i s l a r g e l y the r e s u l t of the t e c h n i c a l nature of the WHO. At the l e v e l of the Executive Board a l l r e p r e s e n t a t i v e s are p h y s i c i a n s ; they share a common professional bond, as medicine has certain universal princples. I t i s only n a t u r a l f o r these i n d i v i d u a l s to d e s i r e an improvement in the health of a l l people, for this i s what they were trained to provide. These physicians are committed to improving i n t e r n a t i o n a l public health and to the current organizational ideology of the WHO: the attainment of the 112 highest l e v e l of health for a l l ; the value of a preventative rather than a curative approach — developing internal health structures, rather than responding to emergencies — they agree that the organization should be universal i n membership and te c h n i c a l i n scope, with p o l i t i c a l i n t r u s i o n s kept to a minimum. 4 0 As well, the issues discussed by the Executive Board are l a r g e l y t e c h n i c a l , d i r e c t l y r e l a t i n g to health. Symbolic decisions involving East-West c o n f l i c t s are rare; those statements occur in 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 national health ministry, they are not concerned with the more p o l i t i c a l issues of state departments. Despite the high degree of technical representation, the WHO has not been completely free from the larger p o l i t i c a l debates that have plagued the United Nations. The World Health Assembly has been subject to the same p o l i t i c a l forces of ideology and p o l i t i c a l manoeuvring. The f i r s t example of such forces at work occurred shortly after the f i r s t session of the World Health Assembly. The Soviet bloc countries withdrew from the o r g a n i z a t i o n c i t i n g t h e i r d i s s a t i s f a c t i o n w ith i t s operation. In r e a l i t y , they withdrew to protest the WHO's f a i l u r e to provide supplies as well as services. Other incidents with strong i d e o l o g i c a l overtones have occurred i n t h i s organization, although f o r the most part the c o n f l i c t today tends to be more North-South than East-West. In the past, p o l i t i c a l resolutions included condemning South A f r i c a 113 and Israel, not for health reasons, but because of ideology. States are not w i l l i n g to collaborate for a l t u r i s t i c reasons; they take action that benefits t h e i r s e l f - i n t e r e s t . To decrease the threat of disease to i n t e r n a t i o n a l business e n t e r p r i s e s and t r a v e l l e r s , developed s t a t e s supported eradication programs. They were also w i l l i n g to devote limited resources to developing countries health i n f r a s t r u c t u r e s , to encourage t h e i r cooperation i n other areas. When i t comes to greater issues of p o l i t i c a l importance, however, states act to preserve t h e i r t r a d i t i o n a l concerns: power and national autonomy. They act according to their national interest. It i s the technical e l i t e s that are responsible for the evolution of the goals of the WHO. They have i n i t i a t e d , on t h e i r own accord, the "Health For A l l Program", which has brought the organization into d i r e c t c o n f l i c t with several multinational firms and a few developed states. 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 organization, but as with other bureaucracies, the WHO had developed a dynamic of i t s own and has evolved i n ways that could not be forseen by the o r i g i n a l signatories to i t s charter. Compliance has ceased to be a concern of t h i s organization. I t was r e a l i z e d by members of the Executive Board that states f a i l e d to comply with regulations, not because of a l a c k of w i l l , but because they lacked the necessary resources to comply. As such, the i n t e r n a t i o n a l health regime i s no longer concerned with regulation; i t i s 114 concerned with helping to provide adequate health measures for every citizen. 115 ENDNOTES - CHAPTER FOUR 1. C. A. Pannenborg, A New International Health Order; An  Inquiry into the International Relations of Health, Alphen aan den Rijn: Sijthoff and Noordhoff, 1979), p. 286. 2. Quoted i n "Malaria: The Change i n Strategy" (Geneva: The  Chronicle of the World Health Organization, Vol. 13, # 9-10., p. 342. 3. Neville Goodman, International Health Organizations and  Their Work, (Baltimore: The Willams and Wilkins Co, 1971), p. 77. 4. Ibid., p. 78. 5. D.M. Leive, International Regulatory Regimes: Case  Studies in Health, Meterology, and Food. (Lexington, Ma.: Lexington Books, D.C. Heath, 1976) p. 10. 6. Ibid., P- 142. 7. Ibid., P- 148. 8. Ibid., P- 141. 9. Ibis., P- 25. 10. Ibid., P- 31. 11. Fraser Brockington, World Health, (Edinburgh: C h u r c h i l l Livingstone, 1975), p. 155. 12. Leive, P. 96. 13. Ibid., P- 78. 15. Ibid., P- 80. 16. Ibid., P- 84. 17. Ibid., P- 88. 18. Ibid., P- 94. 19. Ibid., P- 58. 20. Ibid., P- 64. 116 21. Ibid., p. 96. India and S r i Lanka (then Ceylon) once extensively infected had passed into the maintenance phase, only to experience some 2,000,000 cases during the years 1967-69. 22. Goodman, p. 252. 23. Ibid., p. 78. 24. i b i d . 25. Interview with Dr. Maureen Law, Deputy Minister of Health and Welfare, and Head, Canada's Delegation to the World Health Assembly, Past Chair of the Executive Board of the WHO. Ottawa, Ont., July 2, 1987. 26. Leive, p. 31. 27. Harold Jacobson, "WHO: Medicine, Regionalism, and Managed P o l i t i c s " in The Autonomy of Influence: Decision Making  in International Organizations, edited by Robert Cox (New Haven: Yale University Press, 1974) p. 178. 28. CA. Pannenbory, A New International Health Order, (Alphen aan den Rijn: Sijthoff and Noordhoff, 1979), pp. 203-204. 29. "WHO and NIEO" Annual Report of the Director General for 1975. Chronicle, v o l . 30,#6 June 1976, p. 215. 30. Ibid., p. 218. 31. Global Strategy for Health for A l l by the Year 2000. (Geneva: WHO, 1982), p. 11. Ibid., p. 12. "WHO at the Crossroads" Chronicle, Vol. 31, #6, 1977, p. 219. Contained in the Preamble to the Constitution. Pannenbourg, p. 23. "WHO at the Crossroads" pp. 209, 217. I am indebted to Dr. Nancy Morrisson of the Department of Sociology, UBC, for pointing out this fact to me. Yves Beigeder, "International Health and Transmantional Business: Conflict or Cooperation" in International Review of Administrative Sciences", March 1983. 32. 33. 34. 35. 36. 37. 38. Facts ascertained i n interview with Mr. Bruce M i l l e r , Department Of External A f f a i r s , Canada, United Nations Directorate. Ottawa, Ont., June 30, 1987. Jackobson, p. 203. 118 CONCLUSION THE DEVELOPMENT AND EVOLUTION OF INTERNATIONAL HEALTH COLLABORATION The aim of t h i s t h e s i s has been to document the progression of international health collaboration, to account for both the success, and the obstacles i t has encountered. As i t has been demonstrated cooperation throughout the development of the international health regime has undergone an evolution, in terms of i t s degree and intensity. THE EVOLUTION OF THE HEALTH REGIME As c o l l a b o r a t i o n i n i n t e r n a t i o n a l h e a l t h grew the international health regime i t s e l f evolved. It surpassed i t s i n i t i a l purpose as a regulatory regime to become a tec h n i c a l assistance-oriented organization. O r i g i n a l l y the regime was only concerned with the regulation of quarantine measures. Through the years the focus of t h i s regime has gradually expanded to i n c l u d e much more than the r e g u l a t i o n of 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 t r a v e l . In i t s second century this regime has become concerned with arresting the spread of disease; i t undertook a program of eradication against certain p e s t i l e n t diseases. These programs did not meet with t o t a l success, but demonstrated to the organization the need to develop the health i n f r a s t r u c t u r e i n the l e s s e r developed countries, where the majority of epidemic diseases were endemic. Assisting states in providing primary health care to t h e i r nationals i s now the 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. This evolution has occurred within the dynamics of the growth in international health regimes. At f i r s t , the sanitary conferences were ad hoc a f f a i r s , convened only when a t h r e a t e n i n g epidemic suddenly presented i t s e l f . The conferences had only one item on the agenda, a temporary s o l u t i o n to e i t h e r impending quarantine r e s t r i c t i o n s , or the establishment of measures to combat the spread of a raging epidemic. Over time i t was r e a l i z e d that the lack of a permanent body to apply and interpret sanitary regulations did not encourage compliance. Thus, the creation of successive 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 , each with g r e a t e r r e s p o n s i b i l i t y and j u r i s d i c t i o n than the one before i t . Membership i n these i n s t i t u t i o n s a l s o expanded; the i n t e r n a t i o n a l health regime went from a l a r g e l y European composition to global membership under the United Nations. The agendas of these regimes have grea t l y expanded from erecting measures to protect against a single, s p e c i f i c disease, to considering several pestilent diseases, as well as d i r e c t i n g research into a myriad of i n t e r n a t i o n a l health concerns and coordinating international technical commissions. Where the i n t e r n a t i o n a l health regime once consisted of p r o h i b i t i v e regulations, i t i s now composed of suggested guidelines and requests. The emphasis of the regime has evolved from the prevention and defense of the developed states 120 to assistance and advice for Third World nations. Regulation has increasingly ceased to be an a c t i v i t y of the health regime. Under the World Health Organization recommendations and requests are the rule. Compliance continues to be problematic in the international health regime; i t does not appear to have signif i c a n t l y improved or deteriorated under any formation of the regime. Within the regime i t s e l f there has been a fundamental change i n leadership. Where the developed European nations 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 countries, i t i s now the issues and concerns of the Third World that dominate the world health agenda. These countries are largely unconcerned with ensuring the reduction in impediments to trade and multinational corporations' a c t i v i t i e s . Instead, they are anxious to ensure the development of t h e i r health i n f r a s t r u c t u r e s and to gain an equal d i s t r i b u t i o n of health resources, in terms of medical personnel, and pharmaceuticals. Under the World Health Organization, the health regime has, in fact, evolved from protecting the i n t e r e s t s of i n t e r n a t i o n a l business from damaging quarantine r e s t r i c t i o n s , to at times posing a direct threat to the interests of large multinational corporations. In s p i t e of the great scope of t h i s evolution i t has not been free of c o n f l i c t or p o l i t i c a l opposition. As t h i s t h e s i s has suggested there have been several obstacles to 121 achieving complete cooperation in international health. OBSTACLES TO INTERNATIONAL HEALTH COLLABORATION Sta t e s were, at f i r s t , r e l u c t a n t to p a r t i c i p a t e i n collaborative ventures to control the spread of disease. They were quite content to follow their own policies of quarantine u n t i l the substantial growth in international trade and travel forced them to accept the necessity of j o i n t action to remove the b a r r i e r s to trade i n d i v i d u a l action had created. Despite states' realization of the necessity of collaborative action, they were unable to reach agreement on the appropriate measures t o be t a k e n . A s c i e n t i f i c debate ove r the means of transmission, and the origns of these diseases was in progress, with states supporting different positions, according to their views regarding quarantine. A lack of s c i e n t i f i c knowledge regarding the e t i o l o g i e s of these diseases was to prevent states from agreeing to a regulatory code f o r f o r t y years. A f t e r these d i s c o v e r i e s were made i n the l a t e 1800s i n t e r n a t i o n a l c o l l a b o r a t i v e e f f o r t s became much easier to instigate. Gradually the need for international health organizations became apparent, to administer the sanitary conferences and to revise the codes that had resulted from these c o l l a b o r a t i v e efforts. Through their experiences in the sanitary conferences states had learned that the coordination of research on an 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 states could then benefit from s c i e n t i f i c advances in epidemiology without 122 d u p l i c a t i n g the process. This encouraged states to support further collaboration in 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 to be posed by in t e r n a t i o n a l health organizations, which had a tendency to develop their own institutional loyalties. Due in part to the benefits that came from p a r t i c i p a t i o n i n t h i s organization, including the delights of l i v i n g i n a foreign, cosmopolitan c i t y such as Paris, the employees of the OIHP developed a loyalty to the aims and process of their organization. Similar to other employees in a large bureaucracy, they were resistant to changes i n the organization that could either threaten their p o s i t i o n or the i n s t i t u t i o n i t s e l f . The OIHP was l a r g e l y s t a f f e d by veterans of the early Sanitary Conferences. They brought to t h i s new organization t h e i r b e l i e f s i n the aims of in 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 formed, i n part, by these conferences. These members were, therefore, not keen on the new developments in international public health care in terms of t e c h n i c a l assistance that the Health Organization of the League intended to provide. Instead, they wanted to continue the goals of the e a r l y s a n i t a r y regime to l e s s e n the impediments to international trade and travel while preventing the spread of epidemic disease from less developed countries. This same process was repeated when the Pan American Sanitary Bureau was to be absorbed into the newly formed World Health O r g a n i z a t i o n . Again the members of the s m a l l e r in s t i t u t i o n objected to a loss in their traditional influence 123 and power. The WHO i s presently experiencing a s i m i l a r situation of bureaucratic revolt in i t s implementation of the Health For A l l Program. The aims of this program, to return to the p r o v i s i o n of primary health care by i n d i v i d u a l states, threatens the large appendage of bureaucratic e l i t e s that have accumulated in the regional offices of the WHO. The l a s t t h ree examples a l l show o b s t a c l e s to the furthering of international health collaboration caused not by s t a t e s , but by 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 z i a t i o n s themselves. After the F i r s t World War i t was generally believed that i n t e r n a t i o n a l health work should be c a r r i e d out under the auspices of the 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 to fo s t e r i n t e r n a t i o n a l goodwill, the League of Nations. Also, there was an obvious need f o r an i n t e r n a t i o n a l health body to respond to the serious typhus and influenza epidemics that struck Europe after the war. Only a coordination of effort at the i n t e r n a t i o n a l l e v e l could adequately respond to t h i s c r i s i s . The League had a mandate to further i n t e r n a t i o n a l t e c h n i c a l cooperation, and i t s health organization became inc r e a s i n g l y involved i n conducting t e c h n i c a l studies on diseases that had a strong international presence. While the League was to be a t e c h n i c a l i n s t i t u t i o n p o l i t i c a l issues did occasionally arise. The French expressed some reluctance to cooperate i n i t i a l l y with countries i t had recently fought against. The United States was also wary of 124 the Soviet Union's p a r t i c i p a t i o n i n the health organization's a c t i v i t i e s ; i t was not to enjoy diplomatic relations with this country u n t i l after the Second World War. To a certain extent, however, p o l i t i c a l disputes were subsumed by the technical goals of the organization. Russia, Germany, and Japan a l l p a r t i c i p a t e d i n the Health Organization of the League's a c t i v i t i e s , even though they did not at the time belong to the League. U l t i m a t e l y , however, the s u c c e s s of t h i s i n t e r n a t i o n a l health organization was t i e d to the success of the League i t s e l f , and as one's c r e d i b i l i t y f a l t e r e d , so did the other's. Throughout the duration of the League, epidemic diseases were l a r g e l y under c o n t r o l i n the developed nati o n s . Consecutive s a n i t a r y codes had been e s t a b l i s h e d and consolidated i n 1903 with amending conferences occurring i n 1912 and 1926. These had, f o r the most p a r t , a b o l i s h e d quarantine and had ensured the minimal o b s t r u c t i o n to i n t e r n a t i o n a l trade and t r a v e l . By t h i s time s c i e n t i f i c knowledge was well developed in the treatment and containment of these diseases, as the Western states had well established s o c i a l welfare systems that provided p u b l i c health care f a c i l i t i e s for their citizens. While the original objectives of the health regime had been f u l f i l l e d , collaborative efforts in international health were to proceed. Adequate sanitary and health provisions were s t i l l needed i n the underdeveloped nations, and with the formation of the 125 World HealthOrganization, providing for these needs became a stated goal of the i n t e r n a t i o n a l health regime. This i s demonstrated by the comprehensive definition of health that the Constitution of this organization contains. At f i r s t , the WHO sought to eradicate disease, as i t s t i l l posed a danger to the i n t e r n a t i o n a l t r a v e l l e r and the multinational corporation setting up a factory in a disease plagued country. It was soon discovered, however, that eradication programs were l i k e l y to encounter fai l u r e because of the lack of medical and sanitation services in the very countries where the diseases were rampant. As well, there were often cultural differences that accounted for the fa i l u r e of eradication programs. Complacency developed once an outbreak was under control and had receded from the c a p i t a l c i t i e s . Many of these underdeveloped countries had neither the resources, nor the w i l l to carry out a f u l l eradication 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 disease were states' f a i l u r e to comply with the regulations of the Sanitary or Health Codes. Noncompliance was extensive for many reasons: a lack of resources to either collect data or transmit i t , f e a r s of f i n a n c i a l l o s s e s to tourism, as w e l l as reprecussions to trade caused by the imposition of excessive measures by other countries as a result of their reporting the existence of a pestilent disease. Admitting an outbreak of a p e s t i l e n t disease c a r r i e d the mark of a Third World country, entailing a loss of prestige for the notifying country. 126 The technical e l i t e s of the WHO soon realized that l i t t l e could be done to stop these acts of noncompliance except the provision of technical aid and health resources to counter the diseases that motivated these actions themselves. As such, the WHO has abandoned regulatory a c t i v i t i e s because they were no longer compatible w i t h i t s o r i g i n a l goals, t e c h n i c a l cooperation. 1 What was needed was the p r o v i s i o n of basic health services on an i n d i v i d u a l country basis. This has become the new guiding p r i n c i p l e of the i n t e r n a t i o n a l health regime. The explanation for this development l i e s in the growing acceptance amongst Western developed states that health care was a fundamental s o c i a l r i g h t . As nation states began to r e a l i z e that they had a r e s p o n s i b i l i t y f o r the health care of their individual citizens they transferred this belief to the i n t e r n a t i o n a l l e v e l . W i t h i n the s o c i e t y of n a t i o n s i t gradually became an accepted norm that the more advanced nations had a responsibility to improve the health of the less fortunate and less developed nations. 2 This principle was not accepted unanimously. Most of the developed countries were not w i l l i n g to provide the less developed countries with the aid needed to develop t h e i r h e a l t h i n f r a s t r u c t u r e s . Large multinational firms have also grown suspicious of the WHO as i t takes 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 regarding the Third World. They are supported by some of the developed states, especially the United States, who 127 do not l i k e the turn i n d i r e c t i o n the WHO has taken since a decolonization i n the 1960s added a large number of Third World countries to the organization. The United States' growing displeasure with this situation has been expressed by a substantial reduction i n i t s budget contribution, causing the WHO great d i f f i c u l t i e s i n meeting i t s r e s p o n s i b i l i t i e s and carrying out i t s programs. This action poses the largest obstacle to the future 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 for the WHO today. The e l i t e of the organization, and a few Western nations, are sympathetic to the p l i g h t of the Third World. These na t i o n s i n c l u d e : Sweden, Denmark, Norway, and the Netherlands. 3 It i s the technical e l i t e s , however, who control the agenda of t h i s organization. As a r e s u l t of an e a r l i e r p o l i t i c a l compromise, established at the League of Nations, members of the World Health Organization's Executive Board are elected on the basis of their technical expertise and as their own persons to represent the aims of the organization, not the positions of their respective governments. This situation has allowed these individuals to guide the organization along the original path suggested by i t s progressive constitution. C o l l a b o r a t i o n i n the World Health O r g a n i z a t i o n has undergone an incredible evolution from the original aims of the sanitary regulations and the health regime, designed to ensure the prevention of the spread of disease and the free flow of trade. Today the organization i s more concerned with improving 128 the general level of health care for a l l of i t s members. The obstacles to international health collaboration were the r e s u l t of many factors: a lack of p o l i t i c a l w i l l to c o l l a b o r a t e ; i n s u f f i c i e n t s c i e n t i f i c knowledge of the e t i o l o g i e s of the p e s t i l e n t d i s e a s e s ; the tendency of in t e r n a t i o n a l health organizations to develop a bureaucratic mentality; a lack of economic and health care resources, and an unwillingness to provide these resources; fear of economic repercussions to trade and tourism; and, the i n t r u s i o n of p o l i t i c a l conflicts into the health arena. INTERNATIONAL RELATIONS THEORY AND INTERNATIONAL HEALTH COLLABORATION The developments i n i n t e r n a t i o n a l h e a l t h collaboration have not occurred without opposition. From the beginning, states have been reluctant to collaborate i n the area of i n t e r n a t i o n a l health. Even when the precedent of co l l a b o r a t i o n had already been well established, and the benefits r e a l i z e d , states continued to object or v i o l a t e the terms of i n t e r n a t i o n a l agreements. The reasons f o r the development of international health collaboration, and for the reluctance of some states to p a r t i c i p a t e , as well as for the evolution that t h i s i n t e r n a t i o n a l regime has undergone, can best be understood with the assistance of International Relations Theory. Of the four themes outlined i n the f i r s t chapter, two best explain the i n s t i g a t i o n and development of international collaboration, while the other two are useful in 129 e x p l a i n i n g the o b s t a c l e s and r e l u c t a n c e of s t a t e s to participate in these ventures. REALISM Realism and Neo-realism are t h e o r i e s t h a t concern themselves with the power of the nation state, e i t h e r within the i n t e r n a t i o n a l system or i n comparison to other states. C l a s s i c a l realism has l i t t l e to say on the p o s s i b i l i t i e s of c o l l a b o r a t i v e e f f o r t s of s t a t e s i n the area of d i s e a s e prevention. I t i s not generally an issue of s u r v i v a l or a fac t o r of power for a state. This explains the d i s i n t e r e s t states o r i g i n a l l y displayed towards health cooperation at the international level; i t was not an issue of p r i o r i t y for them. In response to a threatening epidemic states would become concerned and take preventive measures, but as t h i s c r i s i s receded, the focus of states returned to more c r u c i a l issues, such as the attainment and preservation of power. Neo-realism i s more useful i n explaining the development of i n t e r n a t i o n a l health collaboration. Neo-realism modifies c l a s s i c a l realism, and considers the o v e r a l l welfare of the state to be as important i n guiding i t s actions as preserving i t s power. The state, for neo-realists, acts primarily in i t s s e l f - i n t e r e s t , to protect i t s security or i t s standing i n the international system. The security of a nation state depends upon more than i t s amount of power or m i l i t a r y c a p a b i l i t y . Other factors, such as economic welfare, securing access to s t r a t e g i c resources, and ensuring the well-being of i t s 130 c i t i z e n s become involved. Preserving the s a n c t i t y of the nation state, i t s cultural autonomy, or national sovereignty i s also important, as these factors define what i s a nation state. A state w i l l take action against any development that threatens i t s security, be i t a spreading epidemic or a harmful trade measure. I t w i l l cooperate with other s t a t e s or i n i n t e r n a t i o n a l arrangements when i t i s to i t s benefit, i n increasing some aspect of i t s security. This c o l l a b o r a t i o n cannot come at great c o s t to a s t a t e i n terms of i t s sovereignty or economic welfare. I f i t does, a state w i l l be reluctant to 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. I f a state's interests change, or an international agreement i t has committed i t s e l f to i s no longer 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 hesitate to withdraw from collaborative efforts. W i t h i n the framework of i n t e r n a t i o n a l h e a l t h collaboration, neo-realism best explains the i n i t i a l reluctance of states to collaborate, u n t i l i t became c l e a r l y i n t h e i r self-interest to do so — to ensure trade l i b e r a l i z a t i o n and to control the spread of disease. Even after they had realized the value of collaboration, states would v i o l a t e or f a i l to comply with health regulations they had once agreed to, or be r e t i c i e n t about further collaborative efforts. Throughout the early sanitary conferences there was always a reluctance 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 their interests were protected. Despite the general acceptance 131 of the idea to hold an i n t e r n a t i o n a l sanitary conference, i t was to take almost twenty years before European states would even agree to meet. The French had suggested such a conference as earl y as 1834, yet the f i r s t conference was not held u n t i l 1951. Certain countries were ambivalent to the idea of a sanitary conference; Austria was reluctant to participate in a conference f o r which i t saw no r e a l need. As a landlocked country removed from the source of epidemics, i t was relatively unaffected by t h e i r scourge. B r i t a i n , too, l a t e r expressed a great disdain for the entire conference system. It frequently had to be coaxed to attend conferences with promises that issues that were v i t a l to i t s economic i n t e r e s t s , such as imposing lengthier quarantine on ships passing through the Suez Canal, would not be discussed. States were concerned with forging an i n t e r n a t i o n a l agreement that was favourable to their national interest. They were unwilling to compromise on any convention that would even p a r t i a l l y harm this interest. This i s best demonstrated in the fact that i t took forty-one years before there was to be success in these collaborative ventures; i t was not u n t i l the Seventh International Sanitary Conference i n Venice that a l i m i t e d convention was signed regarding the measures to be taken for ships destined for the Mecca pilgrimages. After this f i r s t success i t was to take the p a r t i c i p a n t s a further ten years before a comprehensive convention on a l l relevant diseases and quarantines would be signed by the participating 132 nations. Even though collaborative efforts repeatedly met with failure, states continued to return to the conference fourm, as they r e a l i z e d that an i n t e r n a t i o n a l s o l u t i o n was needed to s o l v e the common problems of epidemic d i s e a s e and the imposition of stringent and damaging quarantine measures against trade. Yet they were u n w i l l i n g to compromise on a solution that would not be in their best interest. The issues that most concerned states i n the Sanitary Conference centered upon two items. The f i r s t was the national autonomy of a state, and the second was ensuring that t h e i r trading i n t e r e s t s were not harmed. The issue of p o l i t i c a l s o v e r e i g n t y arose s e v e r a l times i n the h i s t o r y of the conferences. Each time a measure was proposed that would r e s t r i c t the traditional j u r i s d i c t i o n of a state there would be a large outcry. The best example of this occurred at the F i f t h International Sanitary Conference when the United States' request f o r permission to be granted to t h e i r nationals to inspect a l l ships bound for US ports was greeted with an emphatic negative by other delegates because i t would be a v i o l a t i o n of t h e i r sovereignty. The European countries f e l t that such an action questioned the c a p a b i l i t y and honour of their medical f a c i l i t i e s . Prestige and status are aspects of international p o l i t i c s that are closely linked to national autonomy and sovereignty. Matters of prestige are usually issues that are unique or c h a r a c t e r i s t i c to one nation. For instance, at the sanitary 133 conferences a l l e f f o r t s to place r e s t r i c t i o n s on the Mecca pilgrimages were rejected by Turkey as an a f f r o n t to i t s re l i g i o n and a violation of i t s cultural autonomy and standing as a nation state. In fact, Turkey did not sign a single Sanitary Conference i n the nineteenth century because almost a l l of them sought to impose s p e c i a l measures against the Muslim pilgrimages. Protecting the i n t e r e s t s of i n t e r n a t i o n a l trade was a constant concern in the early development of the international health regime. States with a large degree of trade traversing the Suez Canal had quite d i f f e r e n t goals to protect at the sanitary conferences than those with lesser trading interests. Countries with s i g n i f i c a n t trade were the most supportive of the r e g u l a t i v e aspects of t h i s regime, while those c l o s e r to the apparent source of the epidemics f e l t p s y c h o l o g i c a l l y at greater r i s k and preferred the s e c u r i t y of s t r i c t quarantine measures. Each grouping of states advocated their respective views on this matter because these measures supported what was best for their national interest and security. The determining fac t o r i n a state's p o s i t i o n regarding the imposition of quarantine was less a reflection of their belief in this method of prevention than i t was a reflection of what would be in the state's long term i n t e r e s t . This point explains Britain's s h i f t i n g opinions regarding the source of the cholera vibro. Britain i n i t i a l l y accepted the general consensus expressed at the Fourth Conference that cholera originated i n India, yet 134 denied t h i s same f a c t twenty years l a t e r at the S i x t h Conference. As time passed B r i t a i n grew more reluctant to p a r t i c i p a t e i n these conferences. This i s evidenced by t h e i r r e j e c t i o n of a Permanent Commission on Epidemics where they expressed a "want of f a i t h i n the value of co-operative international sanitary work". This, no doubt, had a great deal to do with the f a c t that they were always i n the minority, advocating the s u b s t i t u t i o n of medical i n s p e c t i o n s f o r quarantine. Even a f t e r a successful i n t e r n a t i o n a l health regime had been formed, states continued to obstruct c o l l a b o r a t i o n by refusing to comply with measures that c o n f l i c t e d with t h e i r perceived s e l f - i n t e r e s t . This was the case with f a i l u r e s to notify the outbreaks of reportable disease and compliance with the r e g u l a t i o n s concerning the i m p o s i t i o n of e x c e s s i v e measures. States found themselves i n a p o s i t i o n where the question became whether to comply with the n o t i f i c a t i o n 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 notifiable disease. As there was an established history of states imposing excessive measures upon learning of an outbreak, many states f a i l e d to notify the WHO, not wishing to r i s k economic losses to trade or tourism as a result of the imposition of excessive measures. This p r a c t i c e continues unabated even today and has recently been a t t r a c t i n g new followers as a r e s u l t of h y s t e r i a regarding the spread of the 135 AIDS pandemic. States have been greatly concerned with protecting their s e c u r i t y and s e l f - i n t e r e s t throughout the formation of the international health regime. Although this has often disrupted or prevented collaboration when actions have not proven to be i n a s t a t e ' s b e s t i n t e r e s t , i t has a l s o encouraged c o l l a b o r a t i o n for the same reason, when i t serves 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 the i n t e r n a t i o n a l system. A health regulatory regime was formed to protect states from the spread of epidemic disease and to sh e l t e r t h e i r growing tra d e i n t e r e s t s as much as p o s s i b l e from the increasingly damaging effects of quarantine. Yet, as the above examples demonstrate, a Neo-Realist perspective i s perhaps best at explaining the f a i l u r e of states to collaborate as opposed to p r o v i d i n g an e x p l a n a t i o n f o r the i n s t i g a t i o n of c o l l a b o r a t i v e e f f o r t s . Other t h e o r i e s of i n t e r n a t i o n a l r e l a t i o n s are more useful i n accounting f o r the p o s i t i v e developments in the international health regime. LIBERALISM Liberal theories of international relations, as expressed i n the work of Edward Morse and Richard Cooper, predict increases in international collaboration w i l l occur as a result of the modernization process i n i t i a t e d by the forces of industrialization. The world has become more interdependent, and t h i s has caused a major change i n the nature of the 136 international system. In order to enjoy the benefits of strong economic r e l a t i o n s h i p s , states must be w i l l i n g to give up c e r t a i n amounts of national independence and autonomy i n achieving their economic objectives. States have moved beyond the t r a d i t i o n a l r e a l i s t goals of power and s e c u r i t y to more subtle ones such as the expansion of economic well-being and the provision of a more equitable distribution of wealth. As a r e s u l t of modernization the norms of i n t e r n a t i o n a l behaviour have been enlarged. It i s becoming the obligation of wealthy nations to r e d i s t r i b u t e some of the world's wealth to the poorer nations. 4 In order to improve economic welfare, states have been w i l l i n g to reduce b a r r i e r s to the free flow of trade. In explaining the development of the international health regime, liberalism accounts for states' gradual acceptance of the need for the coordination of regulations and the reduction of quarantine measures. States w i l l surrender the autonomy they once guarded to ensure the provision of economic gains to their countries. This development was the major impetus behind international health collaboration. Before states had extensive trading interests, quarantine was merely an inconvenience to t r a v e l l e r s . With the development of e f f i c i e n t means of transportation, quarantine became a serious and c o s t l y impediment to trade. As t h e i r trading interests grew, states gradually came to realize this point and sanitary codes were f i n a l l y concluded to a l l e v i a t e 137 this f i n a n c i a l l y harmful situation. B r i t a i n , as the larg e s t trading nation at that time, provided the strongest opposition to quarantine. Throughout the conferences, i t s position became more belligerent. Other countries came to accept Britain's p o s i t i o n as t h e i r own trading i n t e r e s t s grew. Those with a large degree of trade, 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 to the sources of the disease's spread, Mecca. With the adoption of successful sanitary codes i n the 1890s, the p r i n c i p l e s of the health regime were established. They were strongly suggested by liberalism, that the spread of di s e a s e should be checked by procedures which are not excessively harmful to the progress of international trade. As international health development progressed, improving the economic p o t e n t i a l of a state also became a part of t h i s regime. Developed states were strong supporters of eradication programs, not only because they were to r i d the world of a pestilent disease, thereby ensuring that these countries need never have to guard against them, but also because they made the world safe f o r i n t e r n a t i o n a l business and t r a v e l . Less developed countries were not able to i n s t i g a t e development programs u n t i l a sufficient amount of their population was free from disease. Also, epidemic diseases in these countries posed a serious economic drain i n terms of the los s of a p o t e n t i a l workforce. 138 Liber a l i s m also explains the evolution of the health regime i n the twentieth century. While the former principles have been retained, an addition has recently been made that there should be an equitable d i s t r i b u t i o n of health welfare throughout the world. This e n t a i l s a t r a n s f e r of health resources from the developed states to the lesser-developed ones. The WHO has attempted to implement t h i s new norm with programs of t e c h n i c a l cooperation. Although these measures have not been w e l l r e c e i v e d by a l l s t a t e s , they are, nevertheless, part of the modernization process which Morse describes. C o n f l i c t e x i s t s i n t h i s area of i n t e r n a t i o n a l cooperation because the changes to the i n t e r n a t i o n a l system that modernization has wrought are not yet complete. The s i g n i f i c a n t changes that have already occurred as a r e s u l t of t h i s process include the loss of power by the European states and an increase i n the t o t a l number of states. Both of these changes are reflected in the World Health Organization today, and provide explanations for the development of new programs in this organization that d i f f e r significantly from i t s previous goals, before modernization had changed the fundamental structure of the international system. FUNCTIONALISM As a theory in international relations, Functionalism i s most useful in explaining the advances in health collaboration and the evolution within the health regime. This theory i s based on the essential premise that as a result of the growing 139 complexity of the world, states w i l l no longer be able to provide adequately for their citizens the benefits they have in the past. They w i l l be forced to turn to i n t e r n a t i o n a l technical organizations to provide social welfare goals and to ensure that technical issues that cross national jurisdictions w i l l be administered successfully. These i n t e r n a t i o n a l organizations are to 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 are experts i n the area of collaboration. 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 able to separate the p o l i t i c a l issues from the t e c h n i c a l solutions that are required. As a r e s u l t , c o l l a b o r a t i v e ventures between states i n technical areas w i l l lead to greater l e v e l s of cooperation as states realize the success to be gained from these joint actions. Preventing the spread of disease by developing standard health regulatory codes i s an area that crosses the national j u r i s d i c t i o n of states and needs t e c h n i c a l expertise to be achieved. With the growing amount of trade and t r a v e l that occurred i n the nineteenth century, the spread of contagious diseases became more extensive throughout the world, especially i n Europe. The Sanitary Conferences were an attempt at the international level to resolve this problem and to ensure the free flow of trade. Successful cooperation was not to occur u n t i l s c i e n t i f i c discoveries had been made isolating the causes of epidemic disease. After this discovery, states realized the value and necessity of s c i e n t i f i c and p o l i t i c a l cooperation in t h i s area and i n s t i t u t i o n a l i z e d i t i n the f o r m a t i o n of 140 international health organizations with technical goals. These organizations began to develop a l i f e of t h e i r own, however, and have le d to an evolution i n the health regime and an increase i n collaborative efforts. As f o r the nature of t e c h n i c a l cooperation i t s e l f , the health regime has shown some p o s i t i v e developments. The adoption of the contracting out procedure demonstrates the degree to which the former p o l i t i c a l aspects of the sanitary regulations have been reduced to mere te c h n i c a l issues, not r e q u i r i n g the i m p l i c i t approval of states. The WHO i s dominated by the medical profession: v i r t u a l l y every member of a country's delegation i s a physician, and represents t h e i r country's ministry of health, rather than the more p o l i t i c a l l y motivated departments that are responsible for foreign policy. The successes of the i n t e r n a t i o n a l health regime have occurred as a result of technical cooperation. The eradication of smallpox came about largely because of the highly technical nature of i t s solution. A vaccine was already i n existence. What was needed was an e f f i c i e n t way to inoculate a large enough percent of the population i n an endemic area to stop the transmission of this disease. With international cooperation under the auspices of the WHO, the vaccine and method of injection were successfully modified and smallpox has become a disease of the past. The WHO i s motivated to f u l f i l the ideals of i t s Charter because physicians share the ambition of preventing unnecessary 141 sickness and disease, a belief which they bring with them when they represent t h e i r country at the i n t e r n a t i o n a l l e v e l . Despite the fact that government o f f i c i a l s without t h e i r specialized training may not share their ideals, these health specialists have been remarkably successful i n a few instances of ensuring c o l l a b o r a t i o n on issues which are not i n many of t h e i r country's perceived s e l f - i n t e r e s t . A good example of t h i s i s the WHO/UNICEF code on Marketing of Breast Milk Substitutes, which was regarded by the foreign m i n i s t r i e s of some states as adversely affecting international trade and the f i n a n c i a l p o s i t i o n s of m u l t i n a t i o n a l p h a r maceutical corporations. Yet d e s p i t e the successes i n i n t e r n a t i o n a l h e a l t h collaboration, p o l i t i c a l issues s t i l l arise to interfere with the more technical and collaborative aspects of international health work. This i s e s p e c i a l l y true i n the World Health Assembly, where states are represented by the more p o l i t i c a l f a ctions of 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 to 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 evolution that has occurred within the health regime i s the r e s u l t of the s p e c i a l c h a r a c t e r i s t i c s inherent i n in t e r n a t i o n a l health collaboration. Health i s an area where states have collaborated to a much greater degree than i n other, more p o l i t i c a l , areas of international relations. As 142 health care 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 t r a n s f e r r e d to the i n t e r n a t i o n a l l e v e l . A l l states were e n t i t l e d to enjoy the benefits of good health, and the developed nations had an obligation to assist the less developed ones in achieving this goal. While this ideal has been subject to the same p o l i t i c a l forces as other s o c i a l welfare issues at the i n t e r n a t i o n a l level, such as human rights, health collaboration has been more successful because of the nature of i t s t e c h n i c a l e l i t e s . Medical personnel at the i n t e r n a t i o n a l l e v e l , working with t h e i r colleagues at the national l e v e l , have managed to push collaboration in this regime farther than nation states would like, and the repercussions to this action are now beginning to be f e l t by the o r g a n i z a t i o n , as funds and support are withdrawn. Collaboration has increased within the International Health Regime, and each of the four theories of International Relations sheds l i g h t on a d i f f e r e n t f a c t o r to explain t h i s development. Realism and Neo-Realism best explains the opposition to collaboration, while Liberalism and Functionalism suggest occasions when collaboration w i l l be successful. As f o r the future of i n t e r n a t i o n a l cooperation i n t h i s area, i t appears t h a t i n c r e a s e d c o l l a b o r a t i o n w i l l be inevitable. As AIDS increasingly becomes a global problem, the developed states of the West w i l l be faced for the f i r s t time this century with a threatening epidemic disease for which they 143 have no cure or treatment. This situation has not caused such a panic i n the l e s s developed states as AIDS for them i s yet another disease s t r i k i n g t h e i r population. With i t s sudden appearance i n an almost epidemic form, developed states are erecting b a r r i e r s i n an attempt to stop i t s spread. This i s beginning to pose great d i f f i c u l t i e s for international t r a f f i c and commerce. As well, developing states have been fearful to notify the WHO of the existence of this disease, l e s t i t cause repercusions to t h e i r t o u r i s t industries. Several cases of excessive measures regarding i n t e r n a t i o n a l t r a v e l l e r s have already been reported. These incidents r e c a l l an e a r l i e r period when the i n t e r n a t i o n a l health regime was j u s t being created. As AIDS threatens to bring about similar barriers as quarantine, with equally damaging results, states no doubt w i l l enter into collaborative 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 . A l l the p r i n c i p l e s of the health regime w i l l be strengthened, and the lessons learned from e a r l i e r health collaboration w i l l be applied once again. 144 ENDOTES - CONCLUSION 1. Interview with Dr. Jean Lariviere, Senior Medical Advisor, International Health A f f a i r s Directorate, Department of Health and Welfare, Canada. 2. C. A. Pannenborg, A New International Health Order, (Alphen aan den Rijnl Sijthoff 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 University Press, 1974), p. 214. 4. Edward Morse, Modernization and the Transformation of  International Relations, (New York: The Free Press, 1976), p. 45. 145 BIBLIOGRAPHY Al l e n , C.E. "World Health and World P o l i t i c s " . INTERNATIONAL ORGANIZATION 4. (1950). p. 27-43. Ascher, Charles S. "Current Problems i n the World Health Organization's Program". INTERNATIONAL ORGANIZATION 6. (1952). p. 27-50. Basch, Paul F. INTERNATI0NAL_HEALTH. (New York: Oxford University Press, 1978). Beigbeder, Yves. "International Health and Transnational Business: Conflict or Cooperation" INTERNATIONAL REVIEW OF ADMINISTRATION SERVICES". March 1983. Interview with Yves Beigbeder, former o f f i c i a l of the WHO, August 13, Vancouver, B.C. Berkov, Robert. The World Health Organization: A Study in  Decentralized International Administration. (Geneva: L i b r a i r i e E. Droz, 1957). Biraud, Yves. "The International Control of Epidemics". Bri t i s h Medical Journal. (May 1957). Brockington, F r a s e r . World_Health (Edinburgh: C h u r c h i l l Livingstone, 1975). Chetley, Andrew. The P o l i t i c s of Baby Foods - Successful Challenges to an International Marketing Strategy. (New York: St Martin's, 1986). Claude, Inis. Swords into Ploughshares: The Problems and  Progress of International Organizations. Fourth Edition. (New York; Random House, 1971). Cooper, Richard. Economics of Interdependence: , Economic  P o l i c y i n the A t l a n i t c Community. (New York: McGraw H i l l , 1986). "Evolution of International Cooperation in Public Health" WHO. CHRONICLE. VOL. 12. Forbes, John F. "International cooperation in Public Health and the World Health Organization" in The Theory and Struc- tures of International P o l i t i c a l Economy. Todd Sand-l e r , ed. (Bouder, Co.: Westview, 1980). 146 Gear, H.S. and R Deuetchman. "Disease Control and International T r a v e l : A Review of the I n t e r n a t i o n a l S a n i t a r y Regulations". CHRONICLE of the WORLD HEALTH ORGANIZATION Vol. 10-11. (1956) p. 273-234. Goodman, N e v i l l e M. International Health Organizations and  Their Work. (Baltimore: The Williams and Wilkins Co., 1971). Gu t t e r i d g e , F. "Notes on D e c i s i o n s of the World Health Organization" i n The Effectiveness of International  Decisions. (Dobbs Ferry, N.Y.: Oceana Publications, 1971). "Health Challenges for 1978-83". WHO. CHRONICLE. Vol. 31. Hinman, Harold E. World Eradication of Infectious Diseases. ( I l l i o n i s : Charles Thomas Pub., 1966). Hobson, W. World Healh and History. (Bristol: John Wright and Sons Ltd., 1963). Hoole, Francis. P o l i t i c s and Budgeting in the World Health  Organization. (Bloomington: Indiana U n i v e r s i t y Press, 1976). Howard-Jones, Norman. "The S c i n e t i f i c Background to the Sanitary Conferences" i n CHRONICLE of the World Health Organization. Vol 28, 1975. International Public Health Between the Two World Wars. (Geneva: WHO, 1978) . The Pan American Health Organization: Origins and Evolution. (Geneva: WHO, 1981). _ "The World Health 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" i n PERSPECTIVES IN BIOLOGY AND MEDICINE 2 4 (1981) P. 467-82. Jacobson, Harold K. "WHO: Medicine, Regionalism, and Managed P o l i t i c s " i n the The Anatomy of Influence: Decision Making  i n International Organizations. (New Haven: Yale University Press, 1974). Keohane, Robert A. "The Demand for International Regimes" in International Regimes, ed. Stephen Krasner. (Ithaca: Cornell University Press, 1983). Krasner, Stephen, e d i t i o r . International Regimes. (Ithaca: Cornell University Press, 1983) . 147 "Landmark i n World Health". WHO. CHRONICLE. Vol 4. Leive, D. M. International Regulatory Regimes: Case Studies in  Health, Meterology, and Food. Two Volumes. (Lexington, Ma.: Lexington Books, O.C. Heath & Co., 1976). Interview with Dr. Jacques LaRiviere, Senior Medical Advisor to the World Health Organization, Health and Welfare Canada, July 2, 1987. Interview with Dr. Maureen Law, Deputy Minister of Health and Welfare, Canada. July 2, 1987, Ottawa. Interview with Barney Miller, Department of External Affairs, Ottawa, June 30, 1987. Mitrany, David. A Working Peace System. (Chicago: Quandrangle Books, 1966). Functional Theory of P o l i t i c s . (London: London School of Economics Press, 1975. Morgenthau, Hans J. P o l i l t i c s Amongst Nations: The Stuggle For Power and Peace. F i f t h Edition. (New York: A l f r e d A. Knoff, 1973). Morse, Edward. Modernization and the Transformation of  International Relations. (New York: The Free Press, 1976) Pannenborg, C. A. A New International Health Order: An Inquiry  into the International Relations of World Health and Medical Care. (Alphen aan den Ri j n ; s i j t h o f f and Noor-dhoff, 1979). Pethybridge, R. "The Influence of International P o l i t i c s on the A c t i v i t i e s of Non-Political Specialized Agencies—A Case Study," POLITICAL STUDIES. Vol. 13 (June, 1965): 247-51. Riggs, Robert E. "The Bank, The IMF and the WHO". JOURNAL OF CONFLICT RESOLUTION. Vol. 24. (1980): 329-357. Si k k i n k , Kathryn. "Codes of Conduct For T r a n s n a t i o n a l C o r p o r a t i o n s : The Case of the WHO/UNICEF Code". INTERNATIONAL ORGANIZATION. (1986): 815-840. S i l v e r m a n , M i l t o n , P h i l i p R. Lee and Mia Lydecker. Prescriptions For Death: The Drugging of the Third World. (Berkeley: University of California Press, 1982). Stein, Arthur. "Coodorniation and Collaboration: Regimes in an Anarchic World". International Regimes, ed. Stephen Krasner. (Ithaca: Cornell University Press, 1983). 148 "Towards New International Sanitary Regulations" WHO CHRONICLE Vol 3. Waltz, Kenneth. Theory of International Relations. (New York: Random House, 1979). "WHO and the New International Economic Order" WHO CHRONICLE Vol. 30. "WHO at the Crossroads". WHO CHRONICLE. Vol. 13 WHO. BASIC DOCUMENTS. (Geneva: World Health Organization, 1983). WHO. The F i r s t Ten Years of the World Health Organization (Geneva: WHO, 1958). WHO. The Second Ten Years of the World Health Organization  1958-1967. (Geneva: WHO, 1982). WHO. Global Strategy For Health For A l l By the Year 2000 (Geneva: WHO, 1982). WHO. Special Program on Aids, 1987. 149 INTERVIEWS Dr. Maureen Law - Deputy M i n i s t e r of Health and Welfare, Ottawa. Past President of the Executive Board of the World Health Organization. Head, Canadian Delegation to the World Health Organization. Dr. Jacques L a r i v i e r e - Senior Medical Advisor to the World Health Organization, Department of Health and Welfare, Ottawa. Mr. Barney M i l l e r - United Nations Directorate, Department of External Af f a i r s , Ottawa. Prof. Yves Beigbeder - V i s i t i n g Professor, Department of P o l i t i c a l Science, UBC - Summer 1987. Past Administrative O f f i c i a l of the World Health Organization. Prof. Nancy Morrisson - Department of Sociology, UBC 

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