The Evolution of Global Health: Tracing Historical Ideas and Practices [Essay]
Newsletter Edition #222 [The Files In-Depth]
Hi,
This week we take a step back, and try to understand current developments in global health in a historical context.
For today’s edition, I have to thank Vivek N. D., an International Relations scholar, who is a part of our Fellowship program this year. In this vast analysis, he traces the antecedents to the International Health Regulations, and global health security as we understand today.
We hope you find this timely and insightful as I have.
Support public interest global health journalism, become a paying subscriber. Tracking global health policy-making in Geneva is tough and expensive. Help us raise important questions, and in keeping an ear to the ground. Readers paying for our work makes this possible.
Our gratitude to our subscribers who help us stay in the game!
In the coming weeks in July and August, we will have fewer editions than usual, taking advantage of a less frantic global health news cycle in Geneva. I also take this time to work on business and operational areas of this initiative. These are urgent and crucial efforts that shape the future and viability of Geneva Health Files.
Thank you for understanding.
In case you missed it from earlier in the week: a wrap of Q2 ‘24 from us. And a new podcast episode!
Until later.
Best,
Priti
Feel free to write to us: patnaik.reporting@gmail.com. Follow us on X: @filesgeneva
I. ESSAY
The Evolution of Global Health: Tracing Historical Ideas and Practices
By Vivek N.D.
The author is an International Relations scholar with an interest in global health governance. He is affiliated with the Department of Political Science, University of Hyderabad, India.
From the rudimentary medical practices in the colonial era to the sophisticated international health systems of today, the journey of global health reflects a dynamic interplay of science, politics and human resilience.
This essay explores this multifaceted journey, uncovering how past endeavours have shaped current global health policy, and continue to influence the initiatives to fight contemporary health challenges. The essay not only highlights pivotal moments and figures, but also underscores the enduring importance of international cooperation in tackling transnational health threats.
Tracing the Arc of International Health to Global Health
The history of global health is a compelling narrative that weaves through centuries of scientific discovery, social transformation and international collaboration. From the early days of colonial medicine, when health interventions often served imperial interests, to the establishment of pivotal institutions like the World Health Organisation (WHO), global health practices have continually evolved to meet the needs of an interconnected world. This evolution has been marked by ground-breaking advancements and critical challenges, such as the eradication of smallpox, the ongoing battle against HIV/AIDS, and the recent COVID-19 pandemic. Understanding this history is crucial for addressing today's global health issues and for fostering a future where health equity is a universal reality.
This essay examines the evolution of global health, beginning with an exploration of its early motives and genesis, tracing back to the roots of colonial medicine and early international health endeavours.
The first section delves into the historical contexts and the driving forces behind the emergence of global health as a distinct field, highlighting key events that shaped its development.
Subsequently, the essay examines the profound impact of globalisation on health, analysing how interconnected economic, social and political dynamics have influenced health outcomes worldwide.
It concludes by emphasising on the complexities of global health governance (GHG) in the era of globalisation, climate change and transnational health threats.
Early Motives and the Genesis of Global Health
The genesis of global health or its predecessor international health can be traced back to the middle of 19th and early 20th centuries when colonial powers began to expand their influence globally, and encountered diverse health challenges in their colonies. Initially rooted in the efforts to manage the health of colonial subjects for economic and strategic reasons, early initiatives laid the groundwork for what would evolve into a more interconnected approach to addressing health on a global scale. As global trade and travel accelerated, the recognition of the interconnectedness of health across borders became increasingly apparent, leading to the emergence of international health cooperation and the early foundations of what we now recognise as global health.
In the 19th century, the emergence of modern medicine and the germ theory of disease revolutionised healthcare practices. This period saw the establishment of public health institutions and the development of vaccines, antibiotics and sanitation measures, which significantly improved health outcomes.
International collaboration in health is often seen as having begun with the International Sanitary Conferences, whose first session took place in 1851. The meeting was an important step towards addressing international health security problems because of its principal focus on harmonising quarantine regulations in the countries that were historically colonial powers of Europe.
The primary focus of the International Sanitary Conferences was to safeguard European economic interest with cross-border diseases being seen as threats to industrialisation and economic growth.
In this context, at the first International Sanitary Conference, Paris on July 23, 1851, it was acknowledged that cholera was not "constantly, essentially, and universally contagious" and that quarantine measures caused delays. The English delegate Anthony Perrier, is understood to have emphasised that "time is money". Quarantine from cholera, then a major health concern, constituted a loss of time, which invariably led to monetary losses. The Spanish medical delegate Pedro F. Monlau, conceded that quarantine measures were necessary, and stated in response that “Public health is gold”. Eventually commerce prevailed, as England's economic interests outweighed public health, and there was stricter control of infectious diseases in those rounds of debates. The conference concluding without reaching an agreement.
The 14 rounds of International Sanitary Conferences, the last of which concluded in 1938, recognised the need for an agreed set of rules and regulations among governments, in order to act as guides to manage cross-border diseases within home countries. At the Seventh International Sanitary Conference in Venice in 1892, participating nations, despite their differences on how health should be managed, signed the first international treaty relating to health protection.
At the same conference, Egypt was charged with the responsibility of containing plague and yellow fever, diseases whose epidemiology were, hitherto, unknown. This kind of organizing the governance of health finds a resonance today with emphasis on collaborative diplomacy, and interconnectedness of both health and international security.
Emergence of Tropical Medicine & the Role of Non-State Actors
The central aim of these sanitary conferences was to protect the wellbeing of European colonial administrators and shield them from the threats posed by diseases from the tropics. Consequently, the field of tropical medicine primarily emerged from this context, closely intertwined with the disciplines of public health and hygiene. Terms like tropical hygiene and medicine in the tropics were prominent during the start of the 20th century. During this period, tropical institutes began to emerge across the European continent, mainly catering to seafarers arriving at ports. A few of these institutes eventually fell under the authority of Public Health Services, particularly in key port cities like London, Hamburg and Antwerp. British pathologist and bacteriologist, Harold Scott succinctly captured the prevailing sentiment of that era. In his examination of tropical medicine more than eight decades ago, he expressed:
“We can then trace how improvements have been brought about, usually first with a view to safeguarding the health of officials and European traders, and later undertaking also the treatment of natives by which two purposes would be simultaneously accomplished - benefit to the health and well-being of the native and further protection of the white man from native-born infection.”
By the mid-19th century, however, a transition occurred in the way global health was understood. The period between 1860s and 1920s saw the participation of Non-Governmental Organisations (NGOs) in the policy-making processes of International Health Governance (IHG), a predecessor to Global Health Governance (GHG). Worthy of note are the International Committee of the Red Cross founded in 1863 and the Rockefeller Foundation’s International Health Foundation set up in 1913. Other notable NGOs included the League of Red Cross Societies in 1919 and the Save the Children Fund of 1919.
The entry of NGOs into IHG shifted the focus of global health policy from a primarily economic safeguard to one that also incorporated humanitarian concern. A bulletin of the League of Red Cross Societies dated October 11, 1919, for instance, declared that the primary aim of the society was to improve sanitary conditions in countries like Poland whose public health had been affected by World War I, with more than 650,000 cases of typhus, a deadly epidemic, recorded in newly independent Poland in 1918 alone. The spread of typhus in Poland was seen to emerge from Russia and Ukraine, countries that fought against the nations that established the Red Cross Society, viz., Britain, America, France, Japan and Italy. This demonstrates that political affiliations and propaganda played a role in shaping how a disease was portrayed to the international community.
In addition, religious organisations were also pivotal in shaping the management of global health alongside NGOs since the mid-19th century. Medical missions, tasked with evangelical conversions, made their presence felt as far east as China where the first Medical Missionary Society was established in the 1840s. The diseases in the colonised nations were viewed as punishments meted out to the native population because of their ‘sins’. Colonised regions, especially those in Africa, were regarded as countries in need of ‘saving’ from dreaded diseases like cholera, typhus, yellow fever and other epidemics.
Between 1851 and 1920, the emphasis was on advocating for a universal healthcare system by endeavouring to involve as many countries as possible in the framework of international governance. This notion of the charitable Global North organisations and governments extended into the later years of the 20th century. In the early 20th century, international health organisations such as the League of Nations Health Organisation, which preceded the WHO, and the Pan American Health Organisation (PAHO), established on 2 December, 1902, came into existence. These organisations aimed to address health challenges transcending national borders, laying the foundation for GHG.
International Health vs Global Health, and the Establishment of WHO
The last twenty years have witnessed notable revisions in paradigms concerning the global dimensions and features of health. International health and global health[1] have always been closely associated with the defence of domestic populations, corporate interests and objectives of mostly developed countries
For instance, the US Institute of Medicine underscored safeguarding the citizens of the USA. According to the International Federation of Pharmaceutical Manufacturers and Associations in 2022, 25% of the top drug companies controlled 40% of the global market. Further, with most of the top pharmaceutical companies based in developed countries, the developing countries market provides potentially lucrative sales for the drug and vaccine industry.
Even today safeguarding citizens first continues to be a priority. For example, in its first Global Health Strategy in 2018, the German federal government prioritised the safety of the Germans and the welfare of Germany's trade abroad. This suggests that many OECD states continue to prioritise their specific interests and goals. This underscores the keen interest of states in expanding their global health influence.
The notion of international health, an extension of the traditional concept of tropical medicine, gained prominence in the latter half of the 20th century, principally during the Cold War era. Its main emphasis was on addressing the health challenges and hardships encountered by under-developed and developing countries. For instance, efforts to prevent and cure infectious illnesses, enhance water quality and sanitation and advance maternal and infant health were the key priorities.
This concept continues to be extensively employed in universities and other scientific institutions today, albeit with an expanded definition that now encompasses issues such as, injuries and the enhancement of health systems beyond non-communicable diseases.
International health strategies also include international aid driven by developed nations and the international organisations that often act as conduits for these countries to alleviate health issues faced in poorer nations. When development assistance first began, it also involved aiding developing countries in resolving their health issues. This antecedent to subsequent foreign development aid and prevailing international collaborations are fairly paternalistic in nature.
During the same period, the concept of public health, initially developed in the developed countries following World War II, gained prominence. Public health, rooted in community health, especially sanitation, immunisation and preventive medicine, differs significantly from personalised medicine in several key aspects. Unlike medical sciences, which focus primarily on personal health issues, public health prioritises the community as a whole. Public health mainly focuses on the social determinants of health (SDH), widespread diseases and health disparities resulting from the inequities in dispersal of economic, social and political circumstances among the population. This understanding of public health has influenced the interpretation of the "global" in global health interventions.
The establishment of the WHO in the 20th century can be traced back to the series of International Sanitary Conferences held in the late 19th century. The realisation that global health challenges required a coordinated, international response led to the establishment of the WHO under the United Nations in 1948, with its constitution entering into force on 7 April, 1948. Thus, the foundation for the WHO's role in GHG was laid through the gradual evolution of international sanitary conferences and their recognition of the requirement for a unified programme to address health challenges on a global scale.
The WHO, made up of 194 nations, established its ‘health for all’ objective in September 1978 at the International Conference on Primary Health Care held in Alma-Ata, Kazakhstan through the Alma-Ata Declaration. The Alma-Ata Declaration of 1978 was a turning point in 20th century public health, emphasising primary health care as the cornerstone for achieving the goal of health for all. The proclamation was imbued with three important ideas: pertinent technology, resistance to elitism in health care and the notion of health as a catalyst for social advancement.
It is important to note that the objective of health for all is included in the field of global health. Yet, the Alma-Ata Declaration faced criticism for its excessive breadth and idealism, along with being faulted for setting an unrealistic timeframe. The tagline ‘health for all by 2000’ was widely criticised as unrealistic. Following the Alma-Ata Declaration, the Rockefeller Foundation which was concerned with determining the most cost-effective health policies, hosted a conference called “Health and Population in Development” in 1979 in Italy. The meeting was based on Julia Walsh and Kenneth S. Warren's paper Selective Primary Health Care, an Interim Strategy for Disease Control in Developing Countries. The meeting sought to identify precise factors contributing to mortality, particularly targeting prevalent ailments afflicting new-borns in impoverished nations, including diarrhoea and conditions stemming from inadequate immunisation.
Although refraining from overt criticism of the Alma-Ata Declaration, they proposed an interim policy for the advancement of fundamental healthcare. They also stressed the need of realistic goals and cost-effective planning. Thus, the term “selective primary health care” presented in the paper and at the meeting, emerged as the new paradigm.
Current Day Policy Responses with Historical Roots
The term “global health” has garnered recognition over the last twenty years and has undergone extension and expansion. The health of people all over the world is shaped by a multitude of factors that extend beyond national boundaries in a highly interconnected world. These include epidemics, the patent wars and long-term change in the earth's climate, all of which have profound implications for public health on a global scale.
The burden of illness has transitioned from communicable diseases to non-communicable diseases (NCDs), prompting increased focus on lifestyle and environmental factors that impact people's health.
Cross-border health issues represent just one facet of the broader scope of global health. In this context, 'global' encompasses a wide array of health issues and transnational factors. These include endeavours like the global eradication of diseases such as polio, challenges like antibiotic resistance, as well as, issues like climate change, migration, food security and urbanisation.
Planetary Health
The idea of planetary health, which has gained traction in recent times among scientists but was already under discussion in the 1970s, is significantly broader and more comprehensive. It clearly acknowledges the ramifications on human well-being due to the actions of people on planet earth. Planetary health entails a perspective on life that prioritises people over illnesses, aiming to mitigate health disparities stemming from factors like income, education, gender, and living conditions. Its objective is to ensure that every individual on the planet can access the right to health and welfare, striving to “leave no one behind”.
The primary concern of planetary health lies in the impact of environmental changes on health of humans. It concentrates on health of humans within the Anthropocene era, addressing the threats posed by climate change and pandemics to human populations and other species. Additionally, it considers the natural habitats supporting these species and the overall health and biodiversity of the biosphere. In other words, by focusing on the impacts of pandemics and climate change on both human and non-human species, as well as their habitats and the overall health of the biosphere, planetary health highlights the complex relationships between human activities and the natural world.
The post-Cold War era witnessed a significant shift in the conceptualisation of well-being on the worldwide stage, transitioning from notions concerning international health to the more encompassing idea of global health. This shift represented a broader recognition that health challenges transcended traditional state boundaries and were shaped by interconnected factors, such as globalisation, migration and environmental changes. In the aftermath of the Cold War, the world began to grapple with emerging threats like HIV/AIDS, emerging infectious diseases and the increasing burden of non-communicable diseases, which required collaborative, global responses.
International Solidarity As a Factor in Global Health
The notion of global health emphasised a more integrated and inclusive technique, highlighting health as a global public good, and underscoring the need for international cooperation, equity. There has been recognition that health is not solely a matter of medical interventions but is also tied to social, economic and political determinants. This shift underscored the interdependence of nations in safeguarding global health and paved the way for the development of international health frameworks and organisations focused on addressing these complex and interconnected challenges.
Today, the truth is international solidarity in global health has come under pressure. The once robust notion of international cooperation in global health has become increasingly tenuous. This fragility became starkly obvious during the COVID-19 pandemic, where global efforts to coordinate responses were often fragmented and inconsistent. Additionally, the ongoing and frustrating negotiations for a new Pandemic Treaty highlight the challenges countries face in reaching a consensus on shared strategies and commitments to prevent and manage future pandemics. This struggle underscores the complexities and obstacles in fostering effective international collaboration in the face of global health crises.
But as the recent adoption to the amendments to the International Health Regulations have shown, progress is possible even as international solidarity in global health has frayed.
[1] Some scholars use the phrases international health and global health interchangeably, whereas others believe that international is a more limited term used to discuss health challenges in the Global South from the Global North’s perspective. In other words, international health is the study of health in nations other than one's own, particularly when such countries are from the Global South. On the other hand, global health's stated purpose is to improve health and prevent and treat illnesses for all people in all nations throughout the world. Thus, global health indicates a shift in emphasis towards issues that impact everyone all over the globe. To put it another way, it includes health programmes and initiatives that address health challenges at the local, national, international and global levels.
Email the author: viveknenmini@gmail.com
II. PODCAST CORNER
Decolonization, localization and WHO
In this episode, Global Health Matters explores the multifaceted history of global health and how the narratives borne out of colonization, geopolitical events, and national ownership of public health inform policy and practices today. Among the narratives is that of the World Health Organization, which is celebrating its 75th anniversary this year.
Host Garry Aslanyan navigates global health history with two guests. Sanjoy Bhattacharya considers the decolonization of global health and the democratic founding of WHO, which holds great promise for WHO’s future. Anne-Emanuelle Birn speaks about the evolution of global health and the rise of other key players that are shaping the health agenda.
Listen here
Garry Aslanyan is the host and moderator of the Global Health Matters podcast. You can contact him at: aslanyang@who.int
This podcast promotion is sponsored by the Global Health Matters podcast.
If you wish to promote relevant information for readers of Geneva Health Files, for a modest fee, get in touch with us at patnaik.reporting@gmail.com.
Did a colleague forward this edition to you? Sign up to receive our newsletters & support Geneva Health Files!
Global health is everybody’s business. Help us probe the dynamics where science and politics interface with interests. Support investigative global health journalism.