World Health Organization

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WORLD HEALTH ORGANIZATION

The World Health Organization (WHO) is one of the sixteen United Nations (UN) specialized agencies, with a mission to promote world health. The organization's broad conception of health as including politicized issues such as poverty, apartheid, and environmental quality has aroused controversy over the years.

Organization and History

The WHO was conceived at the 1945 San Francisco conference at which the United Nations was formed. It came into being on April 7, 1948, after its constitution was ratified by twenty-six of the original sixty-one members. WHO is based in Geneva and has six regional offices: Africa, Europe, Southeast Asia, Americas, Eastern Mediterranean, and Western Pacific. Governance is provided by the World Health Assembly, with representatives from (as of 2005) 192 member states. The assembly selects an executive board, which in turn nominates a director general, who is elected by the assembly for a five-year term.

The original top WHO priorities in 1948 were malaria, maternal and child health, tuberculosis, venereal disease, nutrition, and environmental sanitation. Subsidiary concerns included public health administration, parasitic and viral diseases, and mental health.

WHO is the successor to a series of international Sanitary Commissions, beginning in the nineteenth century, that concentrated on the containment of infectious diseases. Whereas the philosophy of those earlier organizations was to keep infectious diseases out of nations or regions, the philosophy of WHO was to eradicate those diseases wherever they were found, a "total change of perspective" from that of its predecessors (Beigbeder 1998, p. 13).

In the early twenty-first century WHO fields emergency teams of medical professionals who respond to the outbreak of new infectious diseases such as severe acute respiratory syndrome (SARS) and avian flu. WHO also helps member countries create or improve medical schools and services.

Concept of Health

The WHO definition of health is very broad. According to the organization's constitution, health is "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." WHO conceives of health as a fundamental human right and cornerstone of world peace.

In line with its broad definition of health, WHO has been a pioneer in environmental concerns. It was concerned as early as the 1950s about the effects of the eradication of insect species and the peaceful uses of nuclear power.

Although WHO has been most effective as a detail-oriented technical organization concentrating on medical and scientific problems such as smallpox eradication, its broad mandate has opened the door to numerous efforts to politicize it. From the beginning the WHO assembly has debated and voted on resolutions introduced by its members on political topics such as the effect on Palestinian physical and mental health of the Israeli occupation or on Nicaraguan health of U.S. sanctions. From the date Israel joined WHO the Eastern Mediterranean group always held its meetings in Arab capitals to which the Israeli delegates were not permitted to travel, effectively keeping Israel from playing a role in WHO regional activity. This situation was not resolved for more than thirty years, when Israel was invited to join the European region.

The U.S. ambassador William Scranton said in 1976 that "the absence of balance, the lack of perspective and the introduction by the World Health Organization of political issues irrelevant to the responsibilities of the World Health Organization do no credit to the United Nations" (Siddiqi 1995, p. 8).

Smallpox Eradication: A WHO Success

WHO played a lead role in one of the more dramatic medical victories of modern times: the worldwide elimination of smallpox. The organization announced its smallpox campaign in 1966 and was able to declare victory in 1979, at a cost of about $313 million. WHO acted as a clearinghouse for strategy, knowledge, and vaccine and coordinated a worldwide volunteer effort. To date smallpox is the only infectious disease that WHO or any other organization has succeeded in eradicating. Unlike malaria, one of the most visible failures of WHO, smallpox was an easier target because it is transmitted from human to human with no animal vectors, has a low rate of transmission and develops slowly, is easy to diagnose, and is easy to contain with small doses of vaccine.

Malaria: A WHO Failure

In 1955 WHO announced the ambitious goal of worldwide elimination of malaria; by 1960, sixty-five countries and territories had antimalarial programs. Those programs relied primarily on spraying the walls of houses with DDT. In 1966 WHO announced that 813 million people, 52 percent of the at-risk population, had been insulated from the disease. From 1959 to 1966 almost 11 percent of the organization's annual budget was devoted to the malaria campaign. However, things began to backslide soon afterward as malaria cases began to increase in some countries; for example, Pakistan, which had only 9,500 cases in 1968, had 10 million in 1974 (Siddiqi 1995).

By 1969 WHO recognized that the eradication program had failed. Many mosquitoes lived, bred, and bit their victims far away from the house walls that were being sprayed; some forms of shelter did not have walls; some species were becoming resistant to DDT or otherwise had changed their behavior; WHO had failed to account for population migratory patterns; and many countries did not have the infrastructure necessary to support the program. In 1969 WHO acknowledged that the eradication program did not "adequately take into account economic and social factors" in malaria-ridden countries (Siddiqi 1995, p. 163). Subsequently, WHO changed its focus from eradication to control of malaria. The disease continues to be the world's most lethal parasite-borne ailment and the second most important killer after tuberculosis in more than 190 countries inhabited by 40 percent of the world's population (Beigbeder 1998).

Despite its failure to conquer malaria, WHO has continued to attempt the worldwide eradication of infectious diseases. It vowed to eliminate polio by 2005. However, the September 11, 2001, attacks and the perceived intentions of al Qaeda to use any biological weapon available to attack the West led to renewed consideration of whether disease eradication will ever be possible (Roberts 2004).

Infant Formula: A Controversial Initiative

In December 1969 WHO began to focus on the decline in breast-feeding in Third World countries, which it believed might have been attributable to the aggressive promotion of formula substitutes. Many highly political nongovernmental organizations (NGOs) had seized on this issue as an important one, symbolic of the continuing fallout from colonialism and the exploitation of the Third World by multinational companies. In October 1979 WHO and the United Nations International Children's Emergency Fund (UNICEF) cosponsored a conference that was attended by NGOs and the formula industry. WHO, which had accepted a mandate to mediate between the opposing sides, adopted a working document that appeared to the companies to adopt many NGO grievances without citing supporting data. This led to collisions with "important commercial interests" (Beigbeder 1998, p. 76). The conference resulted in no compromises, and the NGO-industry dialogue was discontinued. WHO and UNICEF pressed on, in 1981 adopting nonbinding recommendations to member states relating to the marketing of substitutes for breast milk.

During the formula debate WHO was seen by critics as intervening in an ideological debate without citing firm scientific evidence for the proposition that babies were being harmed or killed by the use of formula instead of breast milk. WHO also was accused by the industry of disregarding social and even medical factors that contributed to the use of formula, such as its use by women with inadequate production of breast milk (Beigbeder 1998).

The Normative Role of WHO

WHO has three different modes of action under its constitution: It can adopt conventions, make regulations, or issue nonbinding recommendations. Whereas the first two actions bind its members to act, the third does not.

In practice most of the work done by WHO has been an exercise of its nonbinding recommendation power. The organization has been extremely reluctant to exercise its normative powers to make binding international law or rules. This is partly attributable to the initial reluctance of the United States to ratify the WHO charter, fearing that its actions would dictate the passage of domestic legislation: "Clearly, WHO's more influential member states have no intention to convert the Organization into a World Ministry of Health, no more than they wish to create a world government" (Beigbeder 1998, p. 15). WHO has proposed a single convention on tobacco that was never adopted. Even its nonbinding recommendations are a "starkly limited tool" (Koplow 2003, p. 143). Some commentators believe that WHO's reluctance to exercise its normative powers is a product of "organizational culture established by the conservative medical professional community that dominates the institution" (Taylor 1992, p. 303). David Koplow has noted that the WHO "has no power to enforce compliance, to mandate any particular resolution of a dispute, or to impose sanctions upon recalcitrant states" (Koplow 2003, p. 145).

Organizational Effectiveness

The organization's executive director Halfdan Mahler asked in 1987 whether WHO was to be "merely a congregation of romanticists talking big and acting small" (Beigbeder 1998, p. 191). His successor, Hiroshi Nahajima, appointed in 1988, said that "in the past, we have tended to be rigid and doctrinaire, when, in fact, the utmost flexibility is called for" (Beigbeder 1998, p. 28).

In a 1991 report the Danish government evaluated the effectiveness of WHO programs in Kenya, Nepal, Sudan, and Thailand and found "weak analytical capacity," a lack of prioritization, and failure to delegate authority (Beigbeder 1998, p. 191). Member nations often lack the resources to pay for the measures recommended by WHO or do not have the infrastructure or commitment necessary to implement them.

In the early years of the twenty-first century WHO, like other UN agencies, experienced a struggle for dominance between its First World and Third World members. While the United States continued to pay 25 percent of the organization's budget, the WHO executive board, only 42 percent of whose members came from Third World nations in 1950, by that time had an overwhelming majority of Third World representation (68 percent) (Siddiqi 1995). The United States and its allies frequently exercised behind-the-scenes influence on the outcome of WHO deliberations in a way that contradicted the apparently democratic and majoritarian structure of the organization. For example, the United States and Russia, the holders of the last publicly known smallpox stocks, were able to set WHO policy on the destruction of those stocks.

Evaluation

When it concentrates on technical cooperation, WHO sometimes has been extremely effective, as it was in eliminating smallpox from the world. However, like its sister UN agencies it has expended a large proportion of its resources and credibility in political and ideological disputes that have detracted from its technical mission.

JONATHAN WALLACE

SEE ALSO Bioethics;Health and Disease.