WHOse health agenda? 70 years of struggle over WHO’s mandate, by Anne-Emanuelle Birn

The Lancet – Like any milestone, WHO’s 70th anniversary offers an opportunity to reflect on its past trajectory and chart the challenges ahead. WHO’s promising mandate for health cooperation, forged amid a short-lived post-war optimism, mapped out a world of possibilities. Yet its realisation has been limited across distinct eras by complex geopolitical, economic, and institutional pressures, ranging from the Cold War rivalry between US and Soviet blocs to contemporary assaults on WHO’s independence by powerful private actors. Notwithstanding these threats, WHO retains its potential as a democratic and publicly accountable organisation serving collective needs equitably and sustainably, but must take courageous steps to achieve this vision.

WHO was not initially envisioned in the UN architecture, whose foremost priority was ensuring post-war stability for global capitalism. But a proposal by a trio of left-leaning health diplomats from Norway, Brazil, and China, buoyed by nascent disease-control tools (eg, penicillin, DDT), propelled WHO’s foundational meeting in 1946. WHO’s remarkably progressive constitution—shaped by a bevy of social medicine advocates—regarded health in social and political terms, as a human right and government responsibility.

Before World War 2, international health authority spanned several multilateral agencies—including the Pan American Sanitary Bureau (PASB), Office International d’Hygiène Publique, League of Nations Health Organisation (LNHO)—colonial medical and military offices, and US-based Rockefeller Foundation (RF). Unlike the beleaguered LNHO, WHO was funded by member country dues and governed democratically through the annual World Health Assembly (WHA). Upon its constitution’s ratification by a majority of UN members on April 7, 1948, WHO was legitimated as the foremost international health authority, even as large swathes of Africa, Asia, and the Caribbean remained under colonial rule impeding membership.

WHO inherited LNHO’s Geneva headquarters, many staff, and roles of standard-setting, data collection, research, surveillance, and epidemic control. Europeans and North Americans were over-represented as permanent scientific staff. The RF provided a pipeline of experts and infrastructure, influencing WHO’s emergent technical and biomedical agenda over its founders’ aspirations for an integrated sociopolitical approach. Cold War tensions soon surfaced. A distrustful USA delayed joining WHO, and starting in 1949 the USSR and most of the Eastern bloc suspended participation until 1956–57, citing dues exceeding assistance levels, ineffectual technical missions, and hiring biases. Such concerns were shared by other non-western countries, which were not in a position to quit the agency. Meanwhile, PASB’s formidable director, former RF strongman Fred Soper, impelled a worldwide structure of six regional offices to prevent WHO headquarters from usurping regional control.

WHO’s first Director-General, Canadian psychiatrist Brock Chisholm, was at loggerheads with US authorities for advocating socioeconomic approaches to public health and with Catholic countries regarding birth control. Heavily US-controlled UNICEF elbowed its way into early campaigns against yaws and tuberculosis, generating perennial turf wars. The RF’s modus operandi was entrenched organisation-wide after Chisholm was replaced by Brazilian physician Marcolino Candau, who had worked with Soper at the RF’s Brazil office, then at the PASB. Candau, serving from 1953 to 1973, oversaw enormous institutional development, with membership burgeoning from an original 26 countries to 121 in 1965, as newly independent nations joined. Staff size rose from roughly 200 persons in 1948 to almost 3200 in 1967, with concomitant budgetary and bureaucratic growth.

With the Soviet bloc inactive and the USA brandishing bilateral and multilateral health aid as a weapon in its anti-communist arsenal, WHO became increasingly subject to US interests. Most prominent was WHO’s DDT-based Global Malaria Eradication Programme, launched in 1955. While malaria had declined in diverse settings thanks to housing and sanitation improvements, swamp draining, and insecticides, this mix of measures was upstaged by DDT, effectively deployed in World War 2’s Pacific theatre. The US chemical industry, lamenting dwindling sales, lobbied for US bankrolling of WHO’s DDT-spraying effort. Bureaucratically, this transpired via “extrabudgetary” funding—that is, “voluntary” contributions that bypassed WHA governance and concentrated agenda-setting power. The campaign helped free several dozen countries from malaria. Yet sub-Saharan Africa, where malaria’s toll was highest, was omitted because eradication was deemed impossible. By 1969, with escalating vector resistance to DDT, alongside environmental concerns and resentment at indifference to infrastructural needs, the eradication goal was abandoned.

Meanwhile, the USSR, after reactivating membership, proposed targeting smallpox since it was biologically and epidemiologically well suited to eradication—and to Soviet disease control and vaccine production expertise. Inaugurated in 1967, WHO’s signal smallpox effort was both technically feasible and enjoyed US–Soviet cooperation, with each party realising diplomatic and economic benefits. After vaccinating up to 1·2 billion people, the campaign culminated in 1980, smallpox becoming the world’s first ever eradicated disease. Despite a heroic narrative, the reality was more complex: tensions emerged between local and international experts; and over 30 endemic countries had to foot two-thirds of the costs. Moreover, mass smallpox vaccination displaced domestic public health priorities, and sometimes coercive measures met with popular opposition.

By the 1960s, Third World activism was mounting at the UN. The Non-Aligned (to either US or Soviet blocs) Movement—demanding sovereignty, the “right to development”, and fair terms of trade—spawned the G-77 (the UN’s largest bloc). Embodied in UNCTAD’s call for a New International Economic Order, these ideas resonated with WHO’s next Director-General, Danish tuberculosis specialist Halfdan Mahler, who led WHO from 1973 to 1988. Even as the smallpox campaign was intensifying, Mahler marshalled a reorientation of WHO, contesting biomedical reductionism, highlighting community agency and sociopolitical approaches, and resurrecting WHO’s founding mandate. Signature efforts included: a health-system-based Expanded Programme on Immunization seeking universal vaccination against six childhood diseases; an intersectoral tropical disease research and training programme; an Essential Medicines programme; and the Ottawa Charter for Health Promotion. Most famously, WHO and UNICEF advanced a primary health care (PHC) agenda that deviated from longstanding vertical campaigns, instead endorsing an integrated “Health for All” goal. Urged by progressive health actors, the Soviets, and G-77 countries, the landmark 1978 International Conference on Primary Health Care convened some 3000 government and civil society representatives in then Alma-Ata, Kazakhstan, USSR. The Alma-Ata Declaration decried “gross inequality” in health within and between countries and underscored health as “a fundamental human right”. To be sure, PHC was no panacea for continuing social injustice in a world order rife with dictatorships, militarism, and shifting to a neoliberal phase of capitalism that rationalised scaled-back public services. Broadly defined PHC was soon undermined by RF-advanced “selective PHC”, executed through UNICEF-led technical child survival campaigns. In parallel, WHO faced pressure from western powers to scale back its “activism”. As with Essential Medicines, WHO–UNICEF’s International Code of Marketing of Breast-milk Substitutes (1981) raised the ire of the pro-corporate Reagan administration, prompting withholding of the USA’s WHO dues in 1986.

WHO was further weakened amid reduced member contributions as the Third World debt crisis and ensuing International Monetary Fund/World Bank structural adjustment exigencies strangled national budgets. By the late 1980s, the World Bank moved in on WHO’s territory, leading the Bamako Initiative’s introduction of user fees in African countries, and the 1993 World Development Report’s advocacy of reduced packages of health services, delimited public spending, and private sector delivery. Through its health sector loans, the World Bank became the dominant international health player. The 1990s heralded a defanging of WHO. The international health field was transmogrified into global health, whose “shared” agenda opened the floodgates to business. With stagnating member dues, the proportion of WHO’s budget outside WHA’s purview climbed from 50% to 80%. Overshadowed by the World Bank and rising public–private partnerships (PPPs), WHO’s authority faded under donor-driven agendas during Japanese Hiroshi Nakajima’s tenure (1988–98); even UNAIDS arose apart from WHO. His successor, former Norwegian Prime Minister Gro Harlem Brundtland (1998–2003), underlined “sustainable development” and spearheaded a global tobacco control treaty, a contentious health-care system ranking, and the Commission on Macroeconomics and Health, echoing the World Bank’s “Investing in Health” mantra. Two mega PPPs, Gavi, the Vaccine Alliance, and the Global Fund, both backed by the Bill & Melinda Gates Foundation, further dislodged WHO, allowing private entities to channel public funds.

Except for Korean Lee Jong-wook’s term as Director-General from 2003 to 2006—when WHO increased access to antiretroviral therapy by challenging WTO’s patent protections and inaugurated its notable Commission on Social Determinants of Health documenting social injustice “killing on a grand scale”—recent years, markedly under Director-General Margaret Chan, of China, from 2007 to 2017, have seen growing incursion of private actors. These include venture philanthropies, such as the Gates Foundation (steering WHO’s polio eradication focus), and the pharmaceutical industry (pushing for dubious stockpiling of antivirals and vaccines and capitalising on the NCD boom), further legitimised through WHO’s 2016 Framework of Engagement with Non-State Actors. Even the Sustainable Development Goals’ call for universal health coverage, heavily championed by WHO, remains agnostic on equitable, comprehensive, and publicly delivered care, countenancing private insurance profiteering. And although the 2003 SARS outbreak stimulated more muscular International Health Regulations, WHO’s donor-earmarked budget constrained actions during the 2014–15 Ebola epidemic.

WHO’s 70th jubilee comes at a critical juncture. Ethiopian Tedros Adhanom Ghebreyesus, Director-General since 2017, may either intensify WHO’s corporate embrace or stand in solidarity with the people’s health. Enabling WHO to heed its constitutional mandate would require: accountable governance and democratic priority-setting by member countries, thereby resisting undue power of private actors; adequate member dues; replacement of “multistakeholder” profit-oriented partnerships with public–public (intersectoral) ones; decision making and regulation predicated on social need, human rights, and sound science; and success defined in terms of health equity, not tallying disease-control activities. Here’s hoping that WHO’s coming decades bring social justice oriented health for all people.

I am grateful to Theodore M Brown, Ramya Kumar, and Laura Nervi for their insightful suggestions on this essay.

 Further reading
  1. Birn, AE. Backstage: the relationship between the Rockefeller Foundation and the World Health Organization, part I: 1940s–1960s. Public Health2014128129–140
  2. Chorev, N. The World Health Organization between North and South. Cornell University Press,Ithaca, NY2012
  3. Cueto, M, Brown, T, and Fee, E. El proceso de creación de la Organización Mundial de la Salud y la Guerra Fría. Apuntes: Revista de Ciencias Sociales201138129–156
  4. Packard, RM. A history of global health: interventions into the lives of other peoples. Johns Hopkins University PressBaltimore2016
  5. Richter, J. WHO reform and public interest safeguards: an historical perspective. Soc Med20126141–150
  6. WHO. Constitution of the World Health Organization. (accessed March 27, 2018)

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