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Which understanding of public health does WHO have?

The World Health Organization (WHO) is a globally significant health organization. It is globally focused, UN supported and highly funded. Charged with the purpose to facilitate the "attainment by all peoples of the highest possible level of health" with health being defined as a "state of complete physical mental and social well-being, not merely the absence of disease or infirmary" it is a key player in world health (WHO: 1946). A globally positioned and well-resourced international institution such as the WHO would certainly have a comprehension of what public health is and has a powerful role in determining the agenda of public health services. Certainly the WHO has a comprehension of its own interpretation of public health, a definition that is congruent with its own agenda. However, although the WHO is an organization primarily involved in providing technical and scientific knowledge, it is in the business of developing information and distributes this information as advice or recommendations to client nations as its role, it may not "understand" completely the implications of many other versions of public health. This is utilizing a definition of understanding as "knowing the meaning of" and is interpreted as more significant in a hierarchy of terms than the definition of conception "to have a though or idea of". (Hornby 1987:939). Furthermore knowledge (and therefore understanding) is a human construct, it is not empirical, and is grounded in the reinforcement of discourses by groups exercising power (Trigg 1992:28-29). This paper will explore this separation of the WHO’s concepts of public health from its deeper understanding, as evidenced by its statements and promulgations regarding its perception of public health, its advice to other nations, and its practice and the way that it puts its conceptions to work. This will be done through an examination of its history and structure, its theory and declared ideas and lastly, through its activities and ability to implement public health initiatives. In addition, if there is to be an evaluation of the WHO’s understanding of public health it is necessary to develop both a clear definition of public health and to comprehend the degree of variation in different understanding of what public health is.

The term public health evokes different ideas and images. One is often asked: Is it a profession, a discipline, or a system? Is it concerned primarily with the health care of the poor? Does it mean working in an urban clinic, or providing clean water and sanitation?

(Merson, Black and Mills 2001:xvii)

Popular conceptions of public health are relegated to its procedures, methods and the infrastructure that it promotes. Other concepts of public health document the components that it is composed of, such as the various disciplines of epidemiology, health policy, bio-statistics, sociology and toxicology (McKinlay and Marceau 2000:25). Still other definitions center on the processes involved in public health, such as Winslow’s (1920) definition, centering on the prevention of diseases, organized community efforts, education and the development of social machinery, with outcome of "organizing these benefits in such a fashion as to enable every citizen to realize his [sic] birthright of health and longevity" (Winslow’s 1920:183). This definition places public health within a framework of social justice in its discussion of "birthrights". More radical analyses sites public health in a political spectrum which locates public health within the realm of social justice and its mechanisms and processes focused on redistributing income and power for the empowerment of people through health (Beuchamp1979:443, Navarro and Shi 2001:491). Throughout this process of seeking a definition it is evident that public health has been conceived of in many different manners and through many different lenses. Public health, in its methodology, practices and philosophies have changed as the understanding of disease and their causation has changed. As McKinlay and Marceau (2000:25) state, "Each epoch has it’s own unique health challenges. The effective solutions of one epoch are not necessarily transferable to another". They further assert that the underlying perceptions and philosophical basis of public health, are under-explored,

Philosophical foundations such as the underlying ontological notions are rarely part of public health discussions, but these are always implicit and lie behind the arguments and reasoning of different viewpoints or traditions

(McKinlay and Marceau 2000:26)

Nijhuis and van der Maesen (1994:1-3) attempt to differentiate two broad social philosophies of public health activities. "Individualism", that is the focus on distinct people and "Collectivism", the focus of categories or social positions. McKinlay and Marceau (2000:26) further layer upon these poles two conceptions of health, the "medical science or mechanistic perspective" which focuses upon disease states and the risk factors which make individuals susceptible to disease. This is contrasted with the "holistic" perception of health that sees the individual sited in their environment and utilizes features of upstream policy change and health promotion. In this concept, philosophies of public health exist and shift as points on this two dimensional matrix, between individualistic medical science at one extreme and collective holistic public health at the other. McKinlay and Marceau (2000) further assert that the core aspect to evaluate in regards to public health is not whether one mode is superior then the other, or a "futile discussion of the best approach", but rather which is more effective and efficient in their approach. However he suggests that an ecological perspective of public health is more appropriate to address "the impending 21st-century health threats presented by global environmental change, dangers to the ecosystem and planetary overload" (McKinlay and Marceau 2000:26-27). Therefore public health could be seen as developing different strategies and perspectives to match the perceptions of health and disease and the methodology reflects these underlying perceptions. However in order to more clearly define what public health is, a differentiation from medicine science is necessary. That is, what is public health not?

Although the interaction between the current medical science of the time and public health has interacted, there are aspects within each that clearly distinguishes them. Feinberg (1994:4-7) differentiates medicine from public health on a number of dimensions. Medicine’s gaze is focused on the individual and the prevention and treatment of diseases within that individual. Its emphasis is upon the diagnosis and treatment of the disease with the support of a health care system. Public health could be conceived as broader in scope. Its gaze is centered on the population and utilizes health promotion and the prevention of disease. Therefore its gaze is necessarily focused upstream towards factors, such as inequality and poverty, which underpin disease and in doing so enlists the resources of many sectors, such as infrastructure, education as well as the health care system. One of the key differences is the engagement in public health in the underlying power structures and politics that affect diseases. As opposed to the medical profession that remains within the status quo of the social system and can be perceived as a feature of it, the actions of public health "seeks to ensure societal conditions under which people can lead healthier lives, minimizing threats to our health that can be averted or lessened only through collective actions aimed at the community" (Kass 2001:1776). It is with this community focus, and the political aspects of addressing these changes that makes public health markedly different from medicine. It is this social gaze that allows theorists like Geronimus (2000:867) to assert that "the association between health and poverty (or, more broadly socioeconomic position) is among the most robust findings of social epidemiology." These unique perceptions of health by the public health discourse, in questioning the underlying basis of the social order, are politicized conceptions. As Navarro states "None other than Virchow, one of the founders of public health, wrote that politics is ‘public health in the most profoundest sense’"(Navarro and Shi 2001:491) Similarly, the WHO has engaged in social discourses of public health.

Throughout this process of defining perceptions of health and the manner in which ill health is to be addressed, the WHO has not been a passive recipient of knowledge. Rather within its role of disseminating health information at a global level, and its main functions of "to set normative standards, to provide technical assistance and advocate for change in health policy" (Godlee 1994:1491) makes the WHO a key voice in any discourse of public health. The WHO has been highly influential in constructing the concepts and perspectives of what health is, a "state of complete physical mental and social well-being, not merely the absence of disease or infirmary" is a definition which has resonated amongst many other key organizations and public health forums.

International Conference on Population and Development (ICPD) held in 1994. Reproductive health has been defined in the conference's programme of action as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes." (Lee et al 1996: 306)

This broad definition, one in which relates closely to collective perceptions of public health rather than the medical model. Furthermore, the WHO’s contribution to a framework for action in public health, The Declaration of Alma Ata (WHO:1978), asserted that

Health is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. (WHO:1978)

This is a politicized statement located in the perception of health as holistic and within a philosophy of health as community constructed. Further sections of the Declaration reinforced the community participation and control and the obligation of governments to provide the infrastructure necessary to affect this change. In the declaration of Alma Ata and in its definition of health, the WHO has been enormously influential in determining how health, and public health is understood. However the WHO has not always had such a focus, the declaration of Alma Ata is a full 32 years onwards from the WHO’s inception. Moreover some would argue that the WHO has begun to retract from such politicized understandings of public health and is "loosing its influence and retreating into it’s technical and biomedical shell" (Godlee 1994:1491). In order to understand these changes in perceptions, it is necessary to track the WHO as an organization over time and similarly track its perceptions and understandings of public health.

In order to understand the WHO’s perception of public health it is necessary to locate the WHO in a historical context. "Health policy doesn’t occur in a vacuum" (UN Chronicle 1999:7) and neither does the WHO operate in a vacuum. As a premier international multilateral institution, the WHO has an allocated budget of $ 900million and has been given a purpose of "the attainment by all peoples of the highest possible level of health" (WHO:1946, Economist 1998:80). It has a large degree of power to determine what the perceptions of health are and influences the actions that national governments take to address health. However its development across time reflects its agenda and the successes and failures of the organizations that preceded it. Moreover its perceptions of public health also reflect the pressures and agendas of those who have funded or supported the WHO throughout its history.

The WHO is not the first example of an international multilateral forum for health concerns, in the same way as the United Nations (UN) was not the first multilateral collective security organization. There were precursors to both of these structures, and similar to the present relationship between the UN and WHO; the agendas of collective security and trade and health contained common elements. Throughout the 17th and 18th century, the increasing global reach of European trading vessels and the development of a world economy based on colonialisation brought sailors and marines in contact with previously unknown pathogens which they spread through their trade contacts and ports (Merson, Black and Mills 2001: xxi). These diseases created severe disruption to trade and to the internal stability of nations.

Concern for trade was the main motive behind the first International Sanitary Conference of 1851 at which 12 countries signed an international convention on quarantine for cholera, plague and yellow fever. Nine more International Sanitary Conferences followed, each with its own convention. By the second half of the 19th century it was widely recognized that only international cooperation could combat the world's deadliest diseases effectively.

(World Health 1998:4)

Further organizations and forums were developed, such as the International Sanitary Bureau, in 1902. Established in Washington, and the predecessor of the Pan American Health Organisation, the office now serves as the WHO’s regional office for the Americas (Godlee 1994:1493). Other key private industry players were the International Health Commission (1913) established by the Rockefeller Foundation (1909) that in 38 years of operation addressed infectious diseases in the third world with the co-operation of governments and funded the development of medical schools in many developing countries. One of the most significant developments was the development of the League of Nations Health Office (LNHO) that provided health related technical assistance to its member nations. Established in 1920 in Geneva and attached to the League of Nations, the collective security organization that emerged post WWI, failed to prevent WWII and from which the US actively distanced itself from. It is significant that the LNHO’s 1926 publication "Weekly Epidemiological Record" has continued as the weekly publication of the WHO (Merson, Black and Mills 2001:xxii). The impetus of the First World War focused attention on public health methodologies for the perpetuation of the power relationships necessary to maintain control over colonies, as Merson, Black and Mills describe,

All these developments were paralleled by the development and strengthening of competencies in public health among the militaries in the United States and Europe, stimulated in great part by the build up and realities of World War I.

(Merson, Black and Mills 2001:xxii)

Others such as Doyal (1979), track the development of international health institutions as driven by the technical knowledge that provided the necessary health support to colonial and military exercises. She asserts that the understandings, the "ideology of the WHO" was "strongly influenced by wartime advances in chemical disease controls, initially developed to reduce the high level of sickness among troops in areas such as North Africa and the Pacific" (Doyal 1979:273). Therefore the state of public health knowledge and the understandings of public health and objectives of previous organizations, both health and security, developed the context of the WHO. Its emergence within the UN conference of 1945 at the end of WWII is a significant factor in understanding its agenda as it related to public health.

The WHO’s history is closely related to that of the development of the United Nations (UN). It is commonly seen as a branch or one of the "specialized agencies" with the "UN Family", with it’s own assembly (The World Health Assembly) constitution and governing bodies (Lee et al 1996:304). The links between these two organizations are evident as the first discussion of the WHO body in its present form occurred within a UN forum, the May 1945 conference in San Francisco which founded the UN. A "world health organization" was proposed by the delegates of Brazil and China, and a constitution for this body was developed in 1946. The World Health Assembly, the body that is to determine the policy and direction of the WHO and elect its executive met in 1948,

The representatives of 53 Member States and 12 observers chose a president (Dr Andrija Stampar of Yugoslavia), appointed a Director-General (Dr Brock Chisholm of Canada), agreed on a structure of six regions with a headquarters in Geneva, chose an emblem, and cut the budget from the proposed 7 million dollars down to 5 million (World health 1998:4)

The Assembly called for a special focus on four concerns "malaria, tuberculosis, venereal diseases, and the need to improve the poor health of mothers and children" (World Health 1998:4). Although these focuses are disease based, underpinning them was a broader definition that sited health in the realm of the community and not only the biomedical factors involved in infectious disease. The definition that emerged was congruent with understanding of the socially determined factors of disease that features strongly in public health discourse.

Brock Chisholm, the Canadian delegate on the United Nations committee that drew up plans for WHO (and who became the Organization's first Director-General), described why its Constitution took such a broad view of health. "The microbe" he said, "was no longer the main enemy: science was sufficiently advanced to be able to cope with it admirably, if it were not for such barriers as superstition, ignorance, religious intolerance, misery and poverty."

(World health 1998:4)

However during it’s first 30 or so years as an organization, the WHO’s effective mandate focused only on two broad activities, "establishing normative standards and providing scientific and technical advice". The WHO’s premier success came with the eradication of smallpox in 1980 which provided the impetus to expand into further eradication programs such as "Roll Back Malaria" and attempting to eradicate TB. However these later programs have met with limited success. (World Health 1998: p6) Although its mandate is global, the mechanisms that the WHO utilized over this period was interacting on a level of the state, distributing technical knowledge and funding specific programs. This had the effect of stabilizing its political perspective, particularly throughout the Cold War, as Godlee (1994) describes,

Between 1948 and 1973 the organisation had only two directors general, and its technical role as a specialist agency for health spared it the political conflicts that were wracking the rest of the United Nations. Dominated by doctors, WHO took an approach to health that was largely disease oriented, and it studiously avoided political or cultural controversy. (Godlee 1994:1491)

As more member states swelled the World Health Assembly, in the late 1960’s its membership almost doubled, the equal voting power of its new members from African, Latin American and Asian regions meant that they could "achieve the two thirds majority required for decisions at the assembly". This brought the WHO in conflict with vested interests and unraveled its policy "of sticking to uncontroversial medical matters" (Godlee 1994:1492). Although it’s promulgations and statements over this period, particularly its concept of health, fits well within the social conception of disease held as a feature of public health. Its actions and methods could not be described as understanding what effective global public health was; it lacked the political and social analysis, it did not focus on the prevailing economic and health inequalities and had neglected a core part of its mandate, its advocacy role.

The third function of the WHO, its international advocacy, "came into the fore with the launch of ‘Health for All’ in 1977, after which the WHO took a key role in influencing international health policy. In this phase of the WHO, its described "heyday of the late 1970s and 1980s" (Godlee 1994:1495), the WHO challenged the perceptions of health and health care provision through asserting that health is a right at the Alma Ata Declaration. It also addressed, some of the upstream health factors in a manner which intersects with understandings of public health. As Godlee (1994) states,

Halfden Mahler, who became director general in the 1970s, brought the relationship between socioeconomic issues and health into focus. Under Mahler's leadership the health effects of multinational corporations' and pharmaceutical companies' policies were confronted. (Godlee 1994:1491)

The core elements of this focus on health advocacy were seen as the launch of Health for All, Primary Health Care and a code of marketing for breast milk substitutes. (Lee et al 1996:305) However there was dissent within the WHO,

Some critics believe that this expansion of the WHO's role, not only within health policy but into broader areas of social policy, has wrongly led the organisation into politically controversial areas. Many believe that its contribution should remain information based, providing the technical knowledge and means to pursue health activities. (Lee et al 1996:304)

Similar to the change in focus of policy directions there was an understanding that a change was necessary with the approaches used by the WHO. Director-General Marcolino Candau called on the WHO to "turn more directly to the consumer and the small communities — the smallest units" and that the WHO’s goal should be "visibly deal with the people’s priorities, and not act as agents of outside forces however benevolent" (World Health 1998:6). This focus on the community and community control, rather than relating to the health ministries of various nations was a significant shift for the WHO and contributed to its development of Primary Health Care, which was more along the path of public health care that the WHO’s other two mandates of technical developments and assigning normative standards. In addressing the health effects of multinational companies, the WHO created of a code of marketing for companies selling breast milk substitutes. This met with violent opposition by the United States, which was the single nation to oppose the proposition on the basis that it restricted trade. Another equally contentious direction was the WHO’s encouragement to many of its poorer member nations to develop their own drugs, to supply essential drug lists. This again brought the WHO in conflict with the US, which withheld it’s contributions to the WHO’s budget in protest in 1985 (Werner and Sanders 1997:171, Godlee 1994:1494-1495). These conflicts created a space for other key multilateral agencies to expand into the role of leading international health agency, such as the World Bank, " the most serious threat to the organisation's monopoly is probably the involvement of the World Bank in health policy." (Economist 1998:81). Although faced with conflict, the WHO in this period had shifted it’s perception from the individualist to the collective and the methodologies it perused were based in societal change even in the face of vested interests rather than the reduction of disease factors. During this period that it could be said that the WHO understood a form of public health which was politicized, socially based and focused upon upstream factors. This perspective was to change again in the early 90s and, it could be argued, the previous understanding of public health was lost.

"In the new WHO, we will be innovative; we will work together," said Dr Brundtland. "We will move health up the political agenda and, at the same time, redefine what "politics" means. For me, political responsibility is the key--political responsibility that every country has in relation to its people. As for the WHO, whatever we can do that is productive, gives lasting, sustainable results, and makes an impact on people's conditions around the world: that's what making a difference is all about." (Mach 1998:303)

The recent directions of the WHO, both in its message and actions, display that again the WHO has constructed its perception of public health away from a rights discourse towards an knowledge of public health which is focused upon providing technical knowledge and normative standards directly to national governments. The recent 2000 World Health Report, which reviews and rates health systems has drawn criticism as it concludes that what is needed is a greater investment in health care, rather than addressing the inequalities within nations Navarro (2002:31). This focus on the competitive and economic factors of health services provision ranks the US health care system the highest in the world for "responsiveness" and as Navarro further explains,

In general the WHO report shows a well documented bias towards what may be called conventional wisdom in US and increasingly European health care establishments, which promotes managed competition and privatization in the management and delivery of health services as a way of improving the efficiency and responsiveness of health care. (Navarro 2002:31)

Furthermore, the WHO has even critiqued the Alma Ata declaration, for not being "sufficiently sensitive to the market and the needs of the private sector in medicine"(Navarro 2002:33). The focus on private industries and transnational corporations contribution to health is also expanded in current WHO policies. The development of joint programs with multinational drug companies to produce drugs at low cost, is in contrast to its earlier position on encouraging pharmaceutical autarky amongst its member nations. (The Economist 2001:1). In its relationships to other international institutions, the WHO is now returning to its advisory and technical role rather than development or implementation of projects. Increasingly the World Bank is perceived as the key institution involved in international health, as is the Gates foundation, by virtue of disposable funds that are 10-20 times the operating costs of the WHO. Most significantly, the role of managing the global fund for HIV/AIDS has been ascribed to a new multi-sectoral UN agency, UNAIDS. The WHO, "which might, a couple of decades ago, have expected to tackle AIDS alone, is merely one of six collaborators in the program" (The Economist 1998:81). In its role as a technical advisor in this period, from the early 1990’s until present, the WHO has reneged on past statements and perceptions and developed new modes of operating which are exclusive, centralized and reinforce not only the medical sciences model, but also the perpetuation of the inequalities that can be determined to be the underlying cause of ill health. Through this period the WHO has recaptured some of it’s former role as the repository of knowledge regarding public health, however it has lost the understanding of the deeper meanings underpinning this knowledge.

UNICEF and WHO have followed the path of least resistance. Unable to effectively implement their muted call for a more equitable social and economic world order, they tend to embrace stopgap technological interventions as a way to limit the harm done by the present unjust world order- without changing that order or offending it’s dominant interests. (Werner and Sanders 1997:172)

In conclusion, the WHO has existed in the international arena as a Post WWII multilateral institution, closely affiliated with a collective security organ and has therefore operated within the constraints of its own bureaucracy and the limits set upon it by its funders and constituents. Throughout its history it has explored a number of different modes of operation and has covered different conceptual frameworks of public health. Although the WHO may have a concept what its own particular interpretation of public health is, both the shift of it’s perceptions and actions over time relate the lack of any real understanding of the underlying meaning behind public health. It has more of a technical and knowledge based role, and seems to succeed at these tasks far more effectively, with the impetus for understanding coming externally. Either from the newly developing nations of Africa, Latin America and Asia which, by weight of numbers in the World Health Assembly, broadened the WHO’s perspective in health, culminating in the Alma Ata declaration. Or from the financial and free market concepts of its major funders and the significant powers within the UN system. Rather than containing its own inherent understanding of what public health is, the WHO as an institution is a tool which develops health information or perspectives which reflect the understandings and the meanings of public health of those interests which control it.