WORLD HEALTH ORGANIZATION

The World Health Organization (WHO) was created in 1948 by member states of the United Nations (UN) as a specialized agency with a broad mandate for health. The WHO is the world's leading health organization. Its policies and programs have a far-reaching impact on the status of international public health.

Defined by its constitution as "the directing and coordinating authority on international health work," WHO aims at "the attainment by all peoples of the highest possible standard of health." Its mission is to improve people's lives, to reduce the burdens of disease and poverty, and to provide access to responsive health care for all people.

RESPONSIBILITIES AND FUNCTIONS

WHO's responsibilities and functions include assisting governments in strengthening health services; establishing and maintaining administrative and technical services, such as epidemiological and statistical services; stimulating the eradication of diseases; improving nutrition, housing, sanitation, working conditions and other aspects of environmental hygiene; promoting cooperation among scientific and professional groups; proposing international conventions and agreements on health matters; conducting research; developing international standards for food, and biological and pharmaceutical products; and developing an informed public opinion among all peoples on matters of health.

WHO operations are carried out by three distinct components: the World Health Assembly, the executive board, and the secretariat. The World Health Assembly is the supreme decision-making body, and it meets annually, with participation of ministers of health from its 191 member nations. In a real sense, the WHO is an international health cooperative that monitors the state of the world's health and takes steps to improve the health status of individual countries and of the world community.

The executive board, composed of thirty-two individuals chosen on the basis of their scientific and professional qualifications, meets between the assembly sessions. It implements the decisions and policies of the assembly.

The secretariat is headed by the director general, who is elected by the assembly upon the nomination of the board. The headquarters of the WHO is in Geneva. The director general, however, shares responsibilities with six regional directors, who are in turn chosen by member states of their respective regions. The regional offices are located in Copenhagen for Europe, Cairo for the eastern Mediterranean, New Delhi for Southeast Asia, Manila for the western Pacific, Harare for Africa, and Washington D.C. for the Americas. Their regional directors, in turn, choose the WHO representatives at the country level for their respective regions. There are 141 WHO country offices, and the total number of WHO staff, as of 2001, stands at 3,800. WHO is the only agency of the UN system with such a decentralized structure. The Pan American Health Organization (PAHO) existed before the birth of WHO and serves as WHO's regional office for the Americas.

The founding fathers of the UN purposely set aside a network of specialized agencies with their own assemblies, intending that technical cooperation among member states would be free of the political considerations of the UN itself. It has not always worked out this way, however. WHO could not escape entirely the political fights that occurred in the specialized agencies, and the assembly's deliberations have often reflected the political currents of the time.

The decentralized structure of WHO has added a political dimension that has its pluses and minuses. Many of the resources are assigned to the regional centers, which better reflect regional interests. On the other hand, the regional directors, as elected officials, can act quite independently—and occasionally they do. This has given rise to the impression that there are several WHOs.

Moreover, because the regional directors are elected, they need to give consideration to the requirements of reelection. Since the regional directors choose country representatives in their regions, the dynamics of personnel interaction in WHO's administration is quite unique in the UN system. Regional control over country offices is strong, leaving the WHO country representatives with limited authority or leeway for program implementation.

ACCOMPLISHMENTS AND CHALLENGES

The second half of the twentieth century saw remarkable gains in global health, spurred by rapid economic growth and unprecedented scientific advances. WHO has played a very pivotal role in setting health policies, as well as providing technical cooperation to its member states. Life expectancy rose from 48 years in 1955 to 69 years in1985. During the same period, the infant mortality rate fell from 148 per 1000 live births to below 59 per 1000. Population growth has been slowed dramatically in many of the most populous countries. Smallpox, the ancient scourge, has disappeared. Other successes include the control of lice-borne typhus and yaws. Polio and guinea worms are on the verge of total elimination. A number of other communicable and tropical diseases, including onchocerciasis and schistosomiasis, are in retreat. With universal salt iodization in place, the prospect of virtually eliminating iodine deficiency disorders (IDD), the major cause for brain damage among young children, is also in sight.

Absolute poverty is still spreading in many parts of the world, however. Disparities in health and wealth are growing between and within countries. More than one billion people are without the benefits of modern medical science. One out of five persons in the world has no access to safe drinking water. Infectious diseases alone account for 13 million deaths a year, most of them in the developing countries. Seventy percent of the poor are women. The chance of an expectant mother in the world's poorest country dying of childbirth is 500 times greater than her counterpart in the richest country.

Excessive consumption and pollution practices have produced profound climatic changes that impact on the environment and the health of human beings. Globalization of trade and marketing has led to a sharp increase in the use of tobacco, alcohol, and high fat foods, along with unhealthy lifestyles.

THE EARLY YEARS OF WHO

Initially, WHO devoted much of its resources to the fight against the major communicable diseases. Mass campaigns were waged against malaria, trachoma, yaws, and typhus, among others. Malaria turned out to be a more complex problem than anticipated, and early efforts at eradication had to be scaled back to the level of control. Efforts to improve maternal and child health services included the training of traditional birth attendants—an approach advocated by UNICEF, WHO's close partner in all child-health projects—to reduce infant and maternal deaths. WHO also followed up on the work done by its predecessor organizations on sanitary conventions. It adopted, in 1951, the International Sanitary Regulations, later (in 1971) renamed the International Health Regulations.

Beginning in the 1960s, WHO began an effort to extend health services to rural populations. In 1974, recognizing the underutilization of existing technologies to fight childhood diseases, WHO launched an expanded immunization program against polio, measles, diphtheria, whooping cough, tetanus, and tuberculosis.

HFA AND PHC

Widespread dissatisfaction with health services in the later 1960s and early 1970s led to an effort to find an alternative approach to standard health care, and eventually the joint WHO/UNICEF conference in Alma-Ata in 1979.

The goal of Health for All (HFA), adopted by member states at the 1977 World Health Assembly, called for the attainment by all people of the world of a level of health that will permit them to lead a socially and economically productive life. In 1978, WHO and UNICEF cosponsored the historic International Conference on Primary Health Care (PHC) in Alma-Ata, at which the international development community adopted PHC as the key to attaining the goal of Health for All by the year 2000.

PHC, as defined at the Alma-Ata conference, called for a revolutionary redefinition of health care. Instead of the traditional "from-the-top-down" approach to medical service, it embraced the principles of social justice, equity, self-reliance, appropriate technology, decentralization, community involvement, intersectoral collaboration, and affordable cost. The Alma-Ata Declaration on PHC envisaged a minimum package of eight elements:(1) education concerning prevailing health problems and the methods of preventing and controlling them; (2) promotion of food supply and proper nutrition; (3) an adequate supply of safe water and basic sanitation; (4) maternal and child health, including family planning; (5) immunization against the major infectious diseases; (6) prevention and control of locally endemic diseases; (7) appropriate treatment of common diseases and injuries; and (8) provision of essential drugs. Where appropriate, the employment of lay health workers from the community should be trained to tackle specific tasks, including education, and to provide first-level care, with appropriate referrals to secondary and tertiary health facilities.

Though few, if any, countries have successfully followed all the precepts of PHC as enunciated at Alma-Ata, PHC has since provided the philosophical linchpin for virtually all subsequent international health activities. In the 1960s and early 1970s, community health workers and traditional birth attendants were grudgingly accepted by many, though only as second-class health care providers, and they were scorned by others, especially by some traditionally trained allopathic medical practitioners. With Alma-Ata, however, plus the exemplary success of the work of "barefoot doctors" in China, PHC precepts and programs became respectable.

ERADICATION OF SMALLPOX

After an exhaustive and intensive effort, the last cases of smallpox were identified and treated in East Africa. In 1979 a global commission certified the worldwide eradication of this ancient scourge. The cost over the decade-long campaign came to $300 million, a small price to pay for the elimination of the disease, for which the annual cost of vaccination worldwide was close to $1 billion. No ordinary victory, this was humankind's first conquest of a deadly malady, and a clear demonstration that investment in health begets economic benefit as well as humanitarian relief.

GLOBAL STRATEGY FOR HFA

In 1979 the World Health Assembly adopted the Global Strategy for HFA, which was subsequently endorsed by the UN General Assembly. The UN resolution was the health community's attempt to mobilize the world community at large to take collaborative actions to improve the status of the world's health. The main thrust of the strategy was the development of a health-system infrastructure, starting with PHC, for the delivery of countrywide programs that would reach the entire population. The strategy called for the application of the principles of the Alma-Ata Declaration and the development of the minimum package of the eight PHC elements.

HFA was conceived as a process leading to progressive improvement in the health of people and not as a single finite target, though some indicators were recommended. It aims at social justice, with health resources evenly distributed and essential health service accessible to everyone, with full community involvement.

While member states all voted to adopt HFA via PHC, implementation lagged far behind, as economic crises loomed and political and military conflicts flared. Natural disasters also intervened. The rapid rise of the urban poor and weaknesses in the organization and management of health services resulted in waste and misuse of meager resources. Above all, poverty, its deep-rooted causes unresolved, undermined various efforts in the slow march towards HFA.

CSDR, BAMAKO, AND ARI

In the early 1980s, UNICEF launched its Child Survival and Development Revolution (CSDR) with four inexpensive interventions: growth monitoring, oral rehydration, breastfeeding, and immunization programs (commonly referred to as GOBI). After some initial reservation, and with assurances that GOBI efforts would be within the context of PHC, WHO became an active player in CSDR, which has made impressive inroads in reducing infant deaths, especially through the immunization campaign and the oral rehydration program for the control of diarrhea, which also benefited from water and sanitation programs.

WHO also joined UNICEF in launching the Bamako Initiative in the 1980s, which aimed at the provision of essential drugs and their rational use in the context of PHC, initially in African countries but later expanded to other regions. The initiative introduced the element of cost recovery as well as community management of drug supplies and sales. Indeed, in spite of the retrogressive economic situation in Africa south of the Sahara in the 1980s, infant mortality and life expectancy continued to improve gradually in Africa. These gains, however, have since been brutally reversed by the spread of HIV/AIDS.

The 1980s also saw WHO initiating a broad-scale attack against acute respiratory infections (ARI), a major cause of child mortality, and implementing the Safe Motherhood program, designed to reduce maternal deaths—which stood at 500,000 avoidable deaths, almost all in the developing countries. In these efforts, WHO was joined by UNICEF and the World Bank, which had begun to turn some of its attention to the social aspects of development. In the later 1990s, the Integrated Management of Childhood Illness program was launched to bring together a number of programs for a more rational approach.

Though there was progress, the PHC implementation was found to be limited to a number of countries and some specific areas. The principles of PHC, however, were found to be the only viable option even in the most difficult circumstances, with some adjustment of the approaches and strategies necessary in country-specific situations. The effort to introduce district-level PHC did succeed in bringing the services closer to the people who need them.

THE HIV/AIDS PANDEMIC

Although HIV/AIDS first raised its ugly head in the public eye in North America, it soon became clear that the AIDS epidemic was to become a pandemic. Under pressure from WHO, a number of governments, and various developments agencies, the pharmaceutical industry has agreed to allow the price of AIDS treatment drugs to drop from around $15,000 a year per patient in the industrialized countries to $350 in the developing countries. This will encourage more people to come forward for screening in some countries, and in other countries, with help from international organizations, programs of treatment are now a possibility. However, the principal way to fight AIDS is still prevention through education and behavioral change, as work towards an effective vaccine is making very slow progress. While no part of the world is free of the AIDS threat, AIDS spread fast and wide in Africa, especially in countries south of the Sahara. In Asia, where the population pools are much greater, the number of HIV/AIDS cases is expected to exceed that of Africa by 2005.

In fighting AIDS, development agencies of the UN system have joined together to form UNAIDS, in which WHO plays the lead technical role. The pandemic is now such a serious threat to entire societies that it has been brought to the UN Security Council as a matter of grave security concern.

YEAR 2000 GOALS

In 1990, WHO joined with UNICEF in urging the UN Summit for Children to set Year 2000 goals. These goals included increased immunization rates; reduction of infant, under five, and maternal mortality rates; water and sanitation, as well as education for all; the reduction of malnutrition; and the elimination of micronutrient disorders.

After the end of the Cold War, the hope for a "peace dividend" from disarmament did not materialize. On the contrary, with a few exceptions, since that time the volume of development funds from the industrialized countries has shrunk. The 2001 session of the UN General Assembly is likely to be disappointing in its review of the summit goals. The water, sanitation, and education for all goals will certainly fall far short of target. There is still hope, however, for the elimination of polio and guinea worms, as well as the virtual elimination of iodine deficiency disorders.

HEALTH PROMOTION AND OTHER ACTIVITIES

In 1982 WHO undertook a reorientation of health education, designed to expand its community approach and include communication theories and practice. In 1987 the term "health education" was changed to "health promotion" to denote a broader, ecological approach to the work of facilitating "informed choices" by people on health matters.

The first international consultation on this subject was held in Ottawa in 1986, followed by consultations in Adelaide in 1988, Sundsvall in 1991, and Jakarta in 1997. WHO's new approach calls for broader societal involvement, and in the eastern Mediterranean region, member nations adopted social mobilization as the strategy for health promotion. Individual programs, such as the tuberculosis and micronutrient elimination programs, adopted similar stances.

WHO publishes a number of technical journals, the most important of which is the WHO Bulletin, and maintains a media and public relations unit. Every year, World Health Day is observed on April 7, the day, in 1948, when WHO came into being. Each World Health Day is devoted to a particular theme, and material is made available for member states to commemorate the day with a program focus.

Noteworthy, but less publicized, activities of WHO include its worldwide efforts in mental health, oral health, food safety (including the FAO/WHO Codex Alimentarius Commission), health in the work place, elder care, chemical safety, veterinary health, cancer, cardiovascular diseases, and health and the environment. Its essential drug program has had a major impact on the rational use of medicines in developing countries.

WHO maintains a network of collaborating centers, which engage in work in various specific fields. It also maintains a working relationship with a large number of nongovernmental organizations involved in health and development. These organizations are accredited and approved by the World Health Assembly.

YEAR 2020 GOALS

The World Health Assembly has adopted the following set of new goals to be reached by, or before, 2020:

• By 2005, health equity indices will be used within and between countries as a basis for promoting and monitoring equity in health.
• By 2010, transmission of Chagas' disease will be interrupted, and leprosy will be eliminated.
• By 2020, maternal mortality rates will be halved; the worldwide burden of disease will be substantially decreased by reversing the current trends of incidence and disability caused by tuberculosis, malaria, HIV/AIDS, tobacco-related diseases, and violence; measles will be eradicated; and lymphatic filariasis eliminated.
• By 2020, all countries will have made major progress in making available safe drinking water, adequate sanitation, food and shelter in sufficient quantity and
• quality; all countries will have introduced and be actively managing monitoring strategies that strengthen health-enhancing lifestyles and weaken health-damaging ones, through a combination of regulatory, economic, educational, organization-based, and community-based programs.
• By 2005, member states will have operational mechanisms for developing, implementing, and monitoring policies that are consistent with the HFA policy.
• By 2010, appropriate global and national health information, surveillance, and alert systems will be operational; research policies and institutional mechanisms will be operational at global, regional, and country levels; and all people will have access throughout their lives to comprehensive, essential, quality health care, supported by essential public health functions.

WHO has also launched a series of initiatives, including programs to roll back malaria, stop the spread of tuberculosis, fight the AIDS pandemic, and curtail tobacco use. A breakthrough in the drastic reduction of the cost of AIDS treatment drugs is likely to impact the AIDS fight. Negotiation for a tobacco-control convention may lead to greater success for WHO's Tobacco-Free Initiative. With additional resources from private foundations, WHO, in partnership with the World Bank and UNICEF, has launched an ambitious Global Alliance for Vaccines and Immunization (GAVI). Malnutrition, which accounts for nearly half of the 10.5 million deaths each year among preschool children, will continue to be a priority item in the years to come.

WHO has also undergone a number of reorganizations, the latest resulting in nine clusters, each covering a number of programs.

In addition to the two clusters on management and governing bodies, the program clusters are: communicable diseases, noncommunicable diseases, sustainable development and health environments, family and community health, evidence and information for policy, health technology and pharmaceuticals, and social change and mental health.

DIRECTORS GENERAL

There have been a total of five directors general. Dr. Brock Chisholm, a psychiatrist from Canada, was the first. He was succeeded by Dr. Marcolino Candau of Brazil, who ran the organization for twenty years. Dr. Halfdan Mahler, a tuberculosis specialist from Denmark, took the helm after Candau. Mahler oriented the organization towards development, launched the PHC movement, and confronted the infant formula and pharmaceutical industries on health grounds. After fifteen years, he was succeeded by Dr. Hiroshi Nakajima of Japan, who ran the organization for ten years. The current director general is Dr. Gro Harlem Brundtland, a physician from Norway and a former prime minister of that country. Brundtland has placed considerable emphasis on advocacy at the political level.

Jack Chieh-Sheng Ling

(see also: Alma-Ata Declaration; Barefoot Doctors; Blood-Borne Diseases; Communicable Disease Control; Famine; Global Burden of Disease; Health Promotion and Education; HIV/AIDS; Immunizations; Infant Mortality Rate; International Health; Iodine; Maternal and Child Health; Poverty; Sanitation in Developing Countries; Smallpox; Thyroid Disorders; Tropical Infectious Diseases; UNICEF; Waterborne Diseases; World Bank )

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.

BIBLIOGRAPHY

Beigbeder, Yves. (1998). The World Health Organization. The Hague, Netherlands: Martinus Nijhoff.

Koplow, David A. (2003). Smallpox: The Fight to Eradicate a Global Scourge. Berkeley: University of California Press.

Roberts, Leslie. (2004). "Polio: The Final Assault." Science 303: 1960–1968.

Siddiqi, Javed. (1995). World Health and World Politics: The World Health Organization and the United Nations System. London: Hurst.

Taylor, Allyn Lise. (1992). "Making the WHO Work." American Journal of Law and Medicine XVIII(4): 101–346.

World Health Organization

BIBLIOGRAPHY

The World Health Organization (WHO) was established in 1948 when its constitution entered into force. WHO was created to be the United Nations’ specialized agency for health. The WHO’s mission is “the attainment by all peoples of the highest possible level of health” (WHO Constitution, Article 1).

International health cooperation began in the midnineteenth century, and the need for an international health organization was discussed in the latter half of that century. The first half of the twentieth century witnessed the creation of various types of health organizations, both regional (e.g., Pan American Sanitary Bureau, 1902) and international (e.g., Office International de l’Hygiène Publique, 1907; Health Organization of the League of Nations, 1923). WHO’s establishment consolidated international health activities in one organization, membership in which was open to all states. In 2005, 192 states were WHO members.

The WHO Constitution’s preamble defines health as the “state of complete physical, mental, and social wellbeing and not merely the absence of disease or infirmity.” This definition empowers WHO to work on virtually all aspects of communicable and noncommunicable diseases. The WHO Constitution also stipulates that the enjoyment of the highest attainable standard of health is a fundamental human right, and the concept of a “right to health” has helped shape WHO policies.

WHO has three governing organs—the World Health Assembly (WHA), Executive Board (EB), and Secretariat. The WHA is the supreme policy-making body and is made up of representatives from all WHO member states. It meets annually to establish policy for the organization and to make other decisions important to WHO’s operations, such as approving the budget. The EB acts as the WHA’s executive organ and is comprised of representatives from thirty-two WHO member states who are technically qualified in the health field. The Secretariat, headed by a director general appointed by the WHA, is responsible for the technical and administrative aspects of WHO policy implementation.

WHO’s headquarters are in Geneva, Switzerland, but there are also regional offices in the Americas, Europe, the eastern Mediterranean, Africa, Southeast Asia, and the western Pacific. WHO representatives working at the country level provide support to WHO headquarters and regional offices.

Since its establishment, WHO has focused much of its effort on improving health conditions, systems, and policies in developing countries. WHO efforts in this regard have followed two basic approaches. First, WHO has implemented “vertical” programs targeting specific diseases, such as disease eradication efforts. The second approach involves “horizontal” strategies that seek to improve health-system capacities with respect to multiple threats that populations face. WHO’s efforts to ensure universal access to primary health care services provide an example of a horizontal approach.

WHO achieved some success in both vertical and horizontal strategies during the first few decades of its existence. In the late 1970s WHO completed the worldwide eradication of smallpox, an achievement widely regarded as one of the most important public health successes of the twentieth century. WHO also helped developing countries increase childhood immunization rates. Vertical strategies did not, however, always work. For example, WHO’s campaign to eradicate malaria, initially started in the 1950s, did not succeed.

At approximately the same time that WHO successfully eradicated smallpox, it launched the seminal Health for All by the Year 2000 initiative, a horizontal campaign to provide all people, especially those in developing countries, with access to primary health care services. In addition to advancing the concept of the “right to health,” the Health for All effort increased attention to the social determinants of poor health (e.g., poverty, limited education, and racial and gender inequities), which cannot be managed through medical technologies, such as vaccines, but only through social policies linking health with the pursuit of broader social or distributive justice.

These achievements were followed in the 1980s and 1990s by crises that revealed the weaknesses of and problems in WHO. The 1980s witnessed the explosion of HIV/AIDS into a global health problem, particularly for developing countries and especially sub-Saharan Africa. Responsibility for the global response to HIV/AIDS was eventually taken from WHO’s Global Programme on AIDS in 1996 and assigned to a newly created entity, the Joint United Nations Programme on AIDS (UNAIDS). Nevertheless, HIV/AIDS continued to spread globally and, according to UNAIDS, has become one of the worst pandemics in human history.

In the 1990s WHO struggled with the emergence and reemergence of many new and old communicable diseases, a phenomenon made more challenging by the acceleration of globalization that occurred after the end of the cold war. The 1990s also saw WHO trying to address increased morbidity and mortality in the developing world caused by noncommunicable diseases, especially those related to tobacco consumption. WHO’s responses to these mounting global health threats were undermined by leadership and institutional problems at WHO headquarters and regional offices. The failure of WHO member states to achieve the goals of Health for All by the Year 2000 was painfully apparent as the twentieth century came to a close.

Efforts in the latter half of the 1990s and the early 2000s to renew and reinvigorate WHO and its mission have achieved some success, returning credibility and influence to the organization. Key achievements include the successful WHO global response to the 2003 outbreak of severe acute respiratory syndrome (SARS); the adoption of the Framework Convention on Tobacco Control in 2003 as part of the global strategy to reduce tobaccorelated diseases; and the adoption in 2005 of the new International Health Regulations, which represent a significant development for global health governance and for WHO’s authority and responsibility concerning the international spread of disease. WHO has also been active in addressing the benefits and costs globalization presents to health policy, assessing potential synergies and conflicts between health and international trade law (especially within WHO), working with nongovernmental organizations in health-centered public-private partnerships, advancing health components of the UN’s Millennium Development Goals, and pursuing disease eradication (e.g., Global Polio Eradication Initiative).

SEE ALSO Health in Developing Countries; Public Health

BIBLIOGRAPHY

Fidler, David P. 2005. From International Sanitary Conventions to Global Health Security: The New International Health Regulations. Chinese Journal of International Law 4 (1): 1–68.

Goodman, Neville M. 1971. International Health Organizations and Their Work. 2nd ed. London: Churchill Livingstone.

Luca Burci, Gian, and Claude-Henri Vignes. 2004. World Health Organization. The Hague: Kluwer Law International.

Siddiqi, Javed. 1995. World Health and World Politics: The World Health Organization and the UN System. Columbus: University of South Carolina Press.

Tomasevski, Katarina. 1995. “Health.” In United Nations Legal Order, vol. 2, eds. Oscar Schachter and Christopher C. Joyner, 859–906. Cambridge, U.K.: Cambridge University Press.

World Health Organization. http://www.who.int.

David P. Fidler

World Health Organization (WHO)

The World Health Organization (WHO), headquartered in Geneva, Switzerland, is an international group of one hundred and ninety-one member states devoted to the maintenance and improvement of the health of all people throughout the world. Member states are divided into six geographic regions: Southeast Asia, the Eastern Mediterranean, the Americas, Africa, the Western Pacific, and Europe. The director general of the organization oversees the mission to preserve, maintain, and improve health through education, nutritional support, health activities, management of disease outbreaks, response to emergencies, and funding programs.

History and Mission

In 1945, three physicians, Drs. Szeming Sze of China, Karl Evang of Norway, and Geraldo de Paula Souza of Brazil, proposed the formulation of a single health organization that would address the health needs of the world's people. Their joint declaration to establish an international health organization was approved when the constitution of the WHO was adopted in 1946.

The preamble to the constitution defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity." The initial priorities for world health care included initiatives to address malaria , maternal and child health, tuberculosis , venereal diseases, nutrition and environmental sanitation, public health administration, parasitic diseases, viral diseases , mental health, and other activities.

WHO Programs

The WHO provides preventive health and improvement of nutritional status through programs that address:

1. Health education
2. Food, food safety, and nutrition
3. Safe water and basic sanitation
4. Immunizations
5. Prevention and control of local endemic diseases
6. Treatment of common diseases and injuries
7. Provision of essential drugs.

Special programs include the Applied Nutrition Program, which began in 1960 and attempts to improve the nutritional health of people worldwide. Strategic action plans have been developed to promote breastfeeding, support production of foods that improve local diets, distribute supplementary foods, and provide health education. These plans include multiple factors that address the specific needs of each region. The targets of action to accomplish the plans are nutritonal education, safe diets, and healthy choices for living.

WHO and SARS

As Severe Acute Respiratory Syndrome (SARS) broke out in China in 2002, some of the earliest alerts were provided by the Global Public Health Intelligence Network (GPHIN), an automated system that WHO uses to scan Web sites and electronic discussion groups for signs of disease outbreaks that could lead to epidemics. Another WHO system, the Global Outbreak Alert and Response Network (GORAN) links 112 existing networks to monitor and respond to outbreaks of infectious diseases. As SARS came to light, WHO drew on these resources to establish a virtual network of eleven leading laboratories. Using a shared Web site and daily teleconferences to pool information and coordinate activities, they worked to identify the cause of the disease and develop a diagnostic test. WHO's quick response in issuing global alerts and travel advisories and in coordinating international resources have been credited with helping to efficiently contain the spread of the disease.

—Paula Kepos

Food safety is another major focus of WHO special programs. Through the Food Safety Program, contaminants of water and food are identified, with efforts targeted at providing clean sources of food and/or water. Environmental health centers serve as the clearinghouse for activities to support improvement of undernutrition of infants, deficiencies of iodine, vitamin A, and thiamine; anemia , and other nutritional concerns.

Together with UNICEF, the WHO has been successful in overseeing programs to promote breastfeeding and improve the health and nutritional status of pregnant women, infants, and mothers with young children. Hospitals and regional centers have played an important part in the success of this endeavor.

Finally, programs aimed at improving the land and planting crops such as cereals, rice, corn, and potatoes have been introduced in all regions. These programs include production of nutritionally adequate foods to feed those in each region, while also providing education and work opportunities for the people of each region.

Ruth Waibel

Bibliography

Sze, Seming (1982). The Origins of the World Health Organization: A Personal Memoir 1945–1948. Boca Raton, FL: LISZ.

Sze, Szeming (1988). "WHO: From Small Beginnings." World Health Forum 9(1):29–34.

Internet Resources

World Health Organization (1988). "Fifty Years of the World Health Organization in the Western Pacific." Available from <http://www.wpro.who.int/publicpolicy/50th>

World Health Organization (2001). "Report of the Commission on Macroeconomics and Health 2001." Available from <http://www.cmhealth.org>

World Health Organization (WHO)

█ BRIAN D. HOYLE

The World Health Organization (WHO) is the principal international organization managing public health-related issues on a global scale. Headquartered in Geneva, the WHO is comprised of 191 member states (e.g., countries) from around the globe. The organization contributes to international public health in areas including disease prevention and control, promotion of good health, addressing disease outbreaks, initiatives to eliminate diseases (e.g., vaccination programs), and development of treatment and prevention standards.

In 2003, WHO began to coordinate global efforts to monitor the outbreak of the virus responsible for Severe Acute Respiratory Syndrome (SARS). WHO officials also directed aspects of research efforts to identify the specific virus responsible. In addition, WHO officials issued specific recommendations with regard to isolation and quarantine policy and issued alerts for travelers.

Just after the end of World War I, the League of Nations was created to promote peace and security in the aftermath of the war. One of the mandates of the League of Nations was the prevention and control of disease around the world. The Health Organization of the League of Nations was established for this purpose, and was headquartered in Geneva. In 1945, the United Nations Conference on International Organization in San Francisco approved a motion put forth by Brazil and China to establish a new and independent international organization devoted to public health. The proposed organization was meant to unite the number of disparate health organizations that had been established in various countries around the world. The following year this resolution was formally enacted at the International Health Conference in New York, and the Constitution of the World Health organization was approved.

In its constitution, WHO defines health as not merely the absence of disease. A definition that subsequently paved the way for WHO's involvement in the preventative aspects of disease.

From its inception, WHO has been involved in public health campaigns that focused on the improvement of sanitary conditions. In 1951, the Fourth World Health Assembly adopted a WHO document proposing new international sanitary regulations. Additionally, WHO mounted extensive vaccination campaigns against a number of diseases of microbial origin, including poliomyelitis, measles, diphtheria, whooping cough, tetanus, tuberculosis, and smallpox. The latter campaign has been extremely successful, with the last known natural case of smallpox having occurred in 1977. The elimination of poliomyelitis is expected by the end of the first decade of the twenty-first century.

Another noteworthy initiative of WHO has been the Global Program on AIDS, which was launched in 1987. The participation of WHO and agencies such as the Centers for Disease Control and Prevention is necessary to adequately address AIDS, because the disease is prevalent in under-developed countries where access to medical care and health promotion is limited.

Today, WHO is structured as eight divisions addressing communicable diseases, noncommunicable diseases and mental health, family and community health, sustainable development and health environments, health technology and pharmaceuticals, and policy development. These divisions support the four pillars of WHO: worldwide guidance in health, worldwide development of improved standards of health, cooperation with governments in strengthening national health programs, and, development of improved health technologies, information, and standards.

█ FURTHER READING:

ELECTRONIC:

World Health Organization. May, 2003.<http://www.who.int/en/> (May 10, 2003).

SEE ALSO

CDC (United States Centers for Disease Control and Prevention)
Public Health Service (PHS), United States