INTERNATIONAL HEALTH

In its broadest sense international health (sometimes referred to as "global health") is a systematic consideration of all the factors that affect the health of human populations. Among these factors are the genetic, ethnic, and cultural makeup of individuals and groups; the natural environment, including biologic, physical, and climatologic aspects; the political and economic environment; and special circumstances such as population migration, warfare, and violence. Also within the definition is a study of the structure, policies, and functions of the varied components of the health sector. In any one country, the health sector is made up of national and local governmental public agencies, commercial private enterprises, and the many nongovernmental organizations that contribute to improving health.

Persons interested in international health may seek specific training and skills in health or behavioral sciences, economics, anthropology, communications, management, or a wide variety of other fields. International health specialists are employed in colleges and universities, schools of medicine and public health, international or government agencies, humanitarian or charitable organizations, or commercial companies. Some may be self-employed as individual consultants. They may work in fields as diverse as basic biomedical research, immunization policy, implementation of programs in remote communities, or studies of international agencies concerned with health. Some scholars may analyze and compare the medical care systems of the industrialized countries of North America, western Europe, Japan, Australia, or New Zealand. As a practical matter, however, most professionals in this field are concerned with issues such as the control of infectious and other diseases, interactions of health and economic development, education and training, or the financing and operation of medical care institutions in the poorer countries.

GLOBAL HEALTH PROBLEMS

The problems confronted by international health workers can be considered in two main groups: those related to the control of illnesses, injuries, and other threats to individual health; and those related to the provision of medical care services to individuals, and public health services to communities and nations. The major diseases include the widely distributed respiratory and intestinal infections, particularly in the very young; AIDS (acquired immunodeficiency syndrome) and other sexually transmitted diseases; as well as malaria, schistosomiasis, river blindness, and others caused by parasites that are prevalent in tropical regions. Non-communicable and chronic conditions are also of global concern. These include endocrine and metabolic conditions such as diabetes; mental illnesses; disabilities resulting from occupational and environmental hazards; and diseases of the circulatory system, malignancies, dementias, and other conditions that are found mainly in the elderly. Many of these health problems have origins in underlying factors such as poverty, culture and behavior, and the aging of individuals and populations. Regions ravaged by war, civil disturbance, or economic downturn often have outbreaks of diseases such as typhus, diphtheria, or tuberculosis, as well as manifestations of psychological stresses.

In populations throughout the world, patterns of high fertility and high mortality rates have been or are being replaced by low fertility and low mortality rates, a situation known as the "demographic transition." In the typical pattern, economic development and medical interventions generally lead to a rapid reduction in deaths, particularly in infants and children, and a decline in births follows after some time. In the interim, the excess of births over deaths results in a rapid rise in population numbers, a situation now occurring in many developing countries. Improved health further increases fertility by reducing the stresses of pregnancy and by lengthening the reproductive span of both parents. Voluntary family planning programs have been introduced widely to help limit this population increase.

As economic conditions improve and people are living longer, the median age of populations increases and the global burden of ill health is shifting slowly from infectious to chronic diseases. This change in the proportional causes of illness and death is known as the "epidemiologic transition."

In all countries, medical and health care systems are being re-examined. The World Bank's influential World Development Report for 1993, titled "Investing in Health," identified four major problems of health and medical care systems in most countries: misallocation of funds to less cost effective interventions; inefficient use of funds; inequities in access to medical care; and the explosion of health care costs. In 1990 the world spent about $1.7 trillion on health. High-income countries spent about $1,500 per person, or 90 percent of total spending. Low-income countries, with roughly three times the population, spent an average of $41 per person, or 10 percent of the global total. Approximately 1.3 billion people live in absolute poverty, living on less than the equivalent of one U.S. dollar per day.

CLIMATE AND GEOGRAPHY

In addition to the direct effects of altitude, sun exposure, frostbite, drought, flood, and so on, climate and geography affect human health in many ways. Soils and waters may contain an excess or deficiency of iodine, iron, fluoride, arsenic, selenium, or other beneficial or harmful chemical elements. Natural radioactivity may liberate carcinogenic radon gas or may affect human health through foods grown in radioactive soils. In the semidesert areas of the Americas, the fungal spores of valley fever (coccidioidomycosis) present in the soil can be stirred up and inhaled after windstorms or human activities. In sub-Saharan Africa a "meningitis belt" stretches across the Sahel region from Mauritania to Somalia. Here, epidemics of meningitis with high mortality occur during the hot and dry season. The range of food crops and animals that can be grown and raised locally has a great influence on nutrition and well-being. In poor areas where people depend entirely on locally grown food, malnutrition and weight loss may occur on a seasonal basis. Temperature, humidity, and soil type have direct effects on many diseasecausing organisms, such as the larvae of hookworms and the eggs of other parasites. Temperature and humidity are also critical for transmission of diseases carried by vectors such as insects, mites, or ticks. For example, malaria parasites develop best in mosquitoes when the temperature is between 20° and 30° centigrade and the relative humidity is above 60 percent. Oceanic currents and temperatures are related to blooms of plankton that may harbor and disseminate the causative agent of cholera, leading to outbreaks on adjacent shores.

ECONOMICS, CULTURE, AND POLITICS

The most important determinant of the level of health in any population is not the absence or existence of formal health services. It is the degree of economic development, especially the proportion of people living in poverty. The primary cause of ill health is poverty, which produces immense suffering and injustice, frustrates individual potential, and denies the benefits of poverty-stricken individuals' contributions to everyone else. Poorer people everywhere are, on average, less healthy and do not live as long as wealthier people, and this applies to populations and nations as well as to individuals and families. Economic development permits advances in transportation and communication, water supply, electrification, refrigeration, and similar factors that have powerful effects on the level of well-being. Adequate economic and social conditions enable people to make choices about their profession, place of residence, and number of children. Education, particularly of girls and women, is of primary importance to understanding the principles of sanitation and nutrition and recognizing the role of preventive measures such as immunization.

As income rises, health status does not continue to improve indefinitely. There appears to be a level at which basic human needs are met and beyond which health status remains stable or may even decline. Health hazards associated with high incomes include obesity, diseases of the elderly, and those resulting from environmental pollution and degradation.

TROPICAL PUBLIC HEALTH

The concerns of international health workers are often centered on conditions more common in the warmer and economically disadvantaged regions sometimes known as the "third world." The branch of public health that focuses on these issues is often known as tropical public health. Most countries between the tropic of Cancer and the tropic of Capricorn are also poor, and it is the combination of environment and economics that permits infectious and parasitic diseases to thrive. Attention is given also to the provision of health services of acceptable quality and equitable access to such services by all segments of society.

Tropical countries typically have agriculturally based economies, relatively low employment and literacy rates, large numbers of children and youths, few elderly people, and lower life expectancies when compared to the industrialized countries. Because illnesses and deaths in these regions are more commonly caused by viruses, bacteria, and parasites, much of tropical public health is concerned with the control of these infectious agents, with maternal and child health, and similar topics. Large numbers of illnesses and deaths are caused by viral and bacterial pneumonias, viral and bacterial diarrheas, tuberculosis, malaria and other parasitic diseases, and AIDS. Worldwide, major vitamin deficiency diseases such as pellagra, beri-beri, or scurvy are now relatively uncommon, but protein energy malnutrition and deficiencies in microniutrients such as iodine, iron, and vitamin A are frequent expressions of failures of access to adequate diets. Inadequate intake of these three nutrients may lead to goiter, anemia, and blindness, respectively.

Certain diseases characteristic of warm countries are generally known as "tropical" but this description is not always appropriate. Few disease agents or vectors actually require high temperatures to develop, and most can adapt to temperate climates. For example, the United States had repeated epidemics of yellow fever into the early twentieth century, and malaria was endemic in the American South until the 1940s. Rapid air service around the world makes it possible to transport disease agents to areas in which they were previously unknown. For example, in 1999 the mosquito-transmitted West Nile Virus was introduced into New York City from somewhere in Africa, West Asia, or the Middle East. That year, an out-break of human infection resulted in seven known deaths and 62 serious illnesses, emphasizing the need for constant vigilance and international cooperation in infectious disease control.

HEALTH AND MEDICAL CARE SYSTEMS

The health sector in any country embraces two kinds of functions. First are the public health activities such as assuring safe water and food, vector control, reduction of environmental hazards, and collection of statistics. Second is the provision of preventive, curative, and rehabilitative medical services to individuals (i.e., medical care). Within the structure of every sovereign government there is some agency, usually a Ministry of Health (MoH), with responsibility for health-related activities within the country. The various levels of government (national, provincial, district, municipal) may each operate health facilities. In some countries the MoH supervises and regulates the entire health sector, or it may provide medical care directly to some segments of the population. The private sector is often important. In many areas only a minority of the population may make use of government-run health services, preferring to consult pharmacists, healers, or fee-for-service private practitioners. There may be many alternative or competing kinds of providers offering similar services.

Health and medical services are often associated with other public welfare functions such as workers' compensation or retirement systems. Many countries have quasi-governmental organizations, such as social security systems, funded separately from the general tax revenue base.

Medical care systems have complex historical origins in hospitals operated by religious organizations, and voluntary mutual-help groups, whose members agreed to make regular contributions to a pooled fund that would provide cash benefits in the event of sickness, unemployment, or death. Present-day systems have evolved into a great variety of forms with differing levels of comprehensiveness and effectiveness. These can be described here only in the briefest outline.

The first official mandatory social insurance-based system was developed in Germany in the 1880s and has been adopted widely, with modifications, in many countries. In general, workers and employees contribute to pooled funds that negotiate with physicians' organizations to obtain specified services for predetermined fees. Each physician is paid for the amount of services that he or she provides. Governments regulate the process and may or may not add tax money to the system.

The British government has operated the National Health Service (NHS), with modifications, since 1946. The NHS provides comprehensive medical care to all, generally without charge at the point of service. General practice physicians in Britain work as independent contractors and are paid a set fixed fee by the NHS for each patient on that doctor's list regardless of the number of visits. Specialists generally work only in hospitals. The government regulates the NHS and finances its services through collection of taxes.

The former Soviet Union and its satellite states maintained complete government control of all aspects of Soviet public health and medical care. All health care providers were employees of the state, which regulated and financed the entire system. Since the early 1990s this system has ended in Russia and the other countries of central and eastern Europe, and centrally planned economies of this type continue mainly in Cuba and North Korea.

The People's Republic of China has also changed its medical care system in line with political and economic changes. The medical care system was never centralized as in the Soviet model, but consisted of many different Cooperative Medical Schemes based on grassroots insurance plans operated by commune members. By the early 1990s only about 5 percent of rural residents were covered by these plans while the others simply paid for services out-of-pocket. At the end of the 1990s there were many different medical care arrangements based on insurance principles, marked by risk sharing and negotiation with providers and third party payers. In rural areas, funds are generated from households, collectives, and local governments, and used to reimburse certain defined health care expenses. In urban areas, civil servants, college students, and disabled military officers are served by a publicly funded Government Insurance System financed by general tax revenues. Workers in state-owned and collective enterprises are covered by the Labor Insurance System, financed by employer contributions. Others, mainly employees in the private sector, pay privately for their medical care or may belong to one or another employer-sponsored prepaid Health Maintenance Organization.

The island Republic of Singapore has adopted a unique system combining compulsory individual payments and government subsidies. The government maintains control over facilities, medical manpower, and the overall operation of the system. Each citizen must place a percentage of his or her monthly income, matched by employers, into a medical savings account. When that individual is ill or hospitalized, the medical savings account is drawn on to pay the bills. If costs are excessive the government pays the difference. Persons who choose to pay extra can obtain a higher level of service. Singapore also has a thriving private sector, encouraged by the government, for those who elect to use it.

REFORM OF THE HEALTH SECTOR

Dissatisfaction with the health sector is a common feature in all countries, whether wealthy or poor, centrally planned or free market. Common inadequacies of health care systems have already been mentioned. There is a widespread feeling that conventional health expenditures are not cost-effective, and alternative opinions about the public and private sectors are actively debated in many countries. Increasingly complex technology and greater prosperity have led to rising expectations for prevention and treatment of illnesses. Expanding and aging populations place greater demands on health establishments and may outstrip the capacity of local systems.

In the early 1990s, spurred in part by comparative studies supported by the World Bank, health sector reform became established as a specific global strategy. The main goals of health sector reform are to improve the health status and satisfaction of the people; to obtain greater value for money spent on health services by increasing their effectiveness and quality; and to expand equity by improving the access of disadvantaged groups to quality health care. As a general principle, governments are encouraged to focus resources on programs, such as public health–oriented activities, that benefit whole communities rather than particular individuals. The provision and financing of personal clinical services, including diagnosis, preventive and curative procedures, rehabilitation, and supply of pharmaceuticals, is often an area of controversy.

Within a growing awareness of the importance of nongovernment health care providers, health insurance programs of various kinds are promoted to relieve government budgets while protecting households from large financial losses. Governments are encouraged to redefine their role as public sector institutions, trimming down the direct provision of medical care services in favor of setting goals, controlling finances, and managing growth and change in the entire health sector. These goals may be accomplished through regulation, licensing, and monitoring, as well as imposing fees, taxes, subsidies, and incentives. Another widely promoted feature of health sector reform is the decentralization of existing bureaucratic authority for planning, budgeting, and providing government-sponsored health services. Many reform strategies allow for contracting of certain services to enhance the role of private providers in national health systems.

Among the most contentious issues in health sector reform is the promotion of market incentives to augment resources at the local level. User fees for clients of government health facilities have been proposed in situations where public financing is inadequate. Proponents argue that charges for drugs and curative care are the only way to pay for services in impoverished areas. Allowing revenues to be collected and retained as close as possible to the point of service delivery will help both the collection of fees and the efficiency of the service. Opponents say that user fees are regressive, discriminate against the poor, and promote inequity.

HEALTH AND INTERNATIONAL DEVELOPMENT

Development involves a series of directed changes in many aspects of individual, community, and national life. This term refers not only to increasing financial and material resources, but also to aspects of modernization. These include the expansion of technologies that make everyday life more comfortable and productive, and the attitudes that are associated with them. Incorporating these changes into everyday life generally leads to increased receptivity to further change. On a national scale, development includes investment in extractive and agricultural industries, factories, and infrastructure such as roads, dams, water supplies, and electric generation and communications systems. Investment in human potential through adequate educational opportunities, housing, employment, and health care is also important.

DEVELOPMENT AID PROJECTS

Development projects are often targeted toward the health sector in the poorer countries. Such projects are often aimed at strengthening the capacity of health providers to plan, budget, manage, supervise, and evaluate services. Many projects support primary health care systems and infrastructure at community, regional, or national levels. Other projects involve training of health workers of various kinds, providing maternal and child health services including immunization and family planning, the supply of essential drugs, prevention and control of major diseases, and health education. Projects outside the conventional health sector also have a profound impact on health. Construction of infrastructure projects as mentioned, as well as agricultural diversification and expanded opportunities for employment, may improve the health of individuals and communities even more than nominal health projects.

INTERNATIONAL AGENCIES

Early official international health activities began in Venice in 1348, when quarantine, a forty-day detention period for entering vessels, was introduced in an attempt to stop the introduction of plague. Other major European ports also adopted this system. With the growth of international commerce such blockades were increasingly viewed as obstacles to trade. An International Sanitary Conference was held in Paris in 1851, mainly to try to control the frequent epidemics of cholera in Europe. The first international nongovernmental agency, the International Red Cross, was founded in Switzerland in 1864 primarily to promote neutral humanitarian assistance to wounded combatants, has come to be known as the original Geneva Convention. Many conferences and congresses on health and other topics were held in the latter nineteenth century. In 1902 the First Pan American Sanitary Conference in Washington established the International Sanitary Bureau (later named the Pan American Sanitary Bureau) among the nations of the western hemisphere. In 1909 a formal international public health organization, L'Office Internationale d'Hygiène Publique (OIHP) was established, called by English speakers the "Paris Office." The purpose of this office was to collect and disseminate information about public health with an emphasis on infectious diseases such as cholera, plague, and yellow fever. Outbreaks of diseases such as typhus during World War I and the great influenza epidemic of 1918 stimulated the formation of the Health Office of the League of Nations (LNHO), which was never joined by the United States.

Several large international agencies established during and after World War II are important in international health. Discussed here are some components of the United Nations system, primarily the World Health Organization and the World Bank group. The charter of the United Nations (UN) was signed in San Francisco in 1945. The UN family includes many organizations that promote development and health. These include the UN Development Program, the UN Children's Fund (UNICEF), the UN Environment Program, the UN High Commission for Refugees, the World Food Program, the UN Centre for Human Settlements (Habitat), the International Labor Organization, the Food and Agriculture Organization, and the UN Educational, Scientific, and Cultural Organization (UNESCO). By far the most important UN agency for international health is the World Health Organization (WHO).

THE WORLD HEALTH ORGANIZATION

The UN charter contained provision for a specialized health agency with wide powers. In 1946 the Constitution of the World Health Organization was written, and ratified by member states on April 7, 1948. Procedures were set up to take over the remaining duties of the old OIHP, the LNHO, and other existing agencies. The old Pan American Sanitary Bureau remained independent but spun off the Pan American Health Organization (PAHO) as the WHO unit for the Region of the Americas.

The global headquarters of WHO are in Geneva, Switzerland, and there are six subordinate regional headquarters. These are: Copenhagen (Europe); Alexandria (Eastern Mediterranean); New Delhi (Southeast Asia); Harare (Africa); Manila (Western Pacific), and Washington (the Americas). The region of the Americas is divided further into six zones with regional headquarters in Mexico City, Guatemala City, Caracas, Lima, and Rio de Janeiro, as well as the headquarters in Washington. Dr. Gro Harlem Brundtland, former Prime Minister of Norway, was elected Director-General of the WHO in 1998 and quickly organized WHO operations into nine clusters. These clusters are: Sustainable Development and Healthy Environments; Family and Health Services; Social Change and Mental Health; Communicable Diseases; Non-Communicable diseases; Evidence and Information for Policy; Health Technology and Drugs; External Relations and Governing Bodies; and General Management. In 1997 the WHO had 193 members including the countries of the former Soviet Union and some smaller nations such as Andorra. The budget of the WHO is made up of dues from members plus voluntary contributions for special programs such as research on human reproduction; community water supply; tropical diseases; and other purposes. Many projects are paid for jointly by the WHO regular budget, by the country concerned, and by funds from other UN agencies listed above, including the World Bank.

The mission of the WHO as stated in article 1 of its constitution is "the attainment by all peoples of the highest possible level of health," a goal for which some two dozen specific functions are listed in article 2. The work of the WHO is divided into two major categories. The first is central technical services such as information about the occurrence of diseases; international standardization of vaccines and pharmaceuticals; and the dissemination of knowledge through meetings and publications. The second is services to governments, at the request of member countries, usually in the form of specific projects for training, primary care, or specific disease control programs.

THE WORLD BANK GROUP

The great world depression of the 1930s followed by World War II caused many people to believe that increased international organization and regulation would be helpful in preventing monetary and military crises. In 1944 the U.S. government organized the United Nations Monetary and Financial Conference in Bretton Woods, New Hampshire, attended by representatives from 43 countries. That conference established the International Bank for Reconstruction and Development (IBRD), more commonly called the World Bank, the International Monetary Fund (IMF), and the World Trade Organization, which was not formally constituted until 1995. While not primarily health organizations, these agencies, particularly the World Bank, have had a profound influence on international health.

The World Bank (IBRD) lends money to poorer countries for specific types of development projects. During its first decades of operation the bank concentrated its development lending on transportation, public utilities, and certain other infrastructure projects. It was not until the 1980s that the bank provided major support to more human welfare-oriented sectors such as education or health, nutrition and population, which now constitute a substantial proportion of all lending. World Bank project loans are made at prevailing market interest rates. A separate member of the World Bank group, the International Development Association (IDA), was founded in 1960 because the poorer countries were unable to repay standard World Bank (IBRD) loans. Eligible countries with a sufficiently low per capita income receive IDA assistance at much lower interest rates and far better terms. Countries eligible to receive IBRD funding have an annual per capita income below about US$6,000 equivalent, and those that qualify for IDA credits have a per capita income of less than about US$1,000. Many hundreds of specific projects in health, nutrition, population, education, and related fields are funded each year to a total of many billions of dollars.

The International Monetary Fund operates to stabilize monetary and fiscal policies and the liquidity and convertibility of currencies. Countries in financial difficulty may receive support from the IMF on the condition that they adopt certain policies to control inflation and assure international payments. Such conditionalities, called Structural Adjustment Programs, have often been criticized as harmful to the interests of the poor.

ROLES AND FUNCTIONS OF BILATERAL AGENCIES AND NONGOVERNMENTAL ORGANIZATIONS

Beyond their contributions to the large international "multilateral" organizations just described, each of the wealthier industrialized countries has an official agency that provides assistance or "foreign aid" to poorer nations. These bilateral donor agencies generally deal directly with recipient governments. Bilateral agencies commonly provide two broad kinds of assistance: 1) for general economic development, including health projects such as control of malaria, services for mothers and children; or strengthening of health services; and2) for humanitarian relief during periods of natural disaster or civil disturbance. In the United States this role is met by the U.S. Agency for International Development (USAID).

Many development and humanitarian activities are also carried out by a very large number of nongovernmental or private voluntary organizations based in the wealthier countries and supported by religious or private groups, or donations from the public. Such nonprofit organizations often interact directly with local counterparts in the developing world. Some companies in the private sector provide services such as consulting, planning, implementing, or evaluating projects in the field, often funded by contracts from governmental bilateral agencies.

Since the 1950s, multilateral, bilateral, and nongovernmental donors have conducted specific health-related projects in recipient countries. Such projects, negotiated individually with local government officials, consume valuable staff time and result in duplication or gaps in coverage. Some countries are adopting a sector-wide approach, in which multiple donors join in a consortium to deal together with the local government in support of its national strategy.

Paul F. Basch

(see also: Anthropology in Public Health; National Health Systems; Pan American Health Organization; UNICEF; United States Agency for International Development [USAID]; World Health Organization )

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