World Health Organization : The mandate of a specialized agency of the United Nations

PART I : The institution

Chapter 1

ORIGIN AND DEVELOPMENT OF INTERNATIONAL COOPERATION FOR HEALTH :
STEPS TOWARDS THE CONSTITUTION OF THE WORLD HEALTH ORGANIZATION

"Well, it came about quite accidentally", affirms Szeming Sze[1], one of the founding fathers of the World Health Organization (WHO). "The San Francisco Conference was being held so that countries could pledge themselves to establish the United Nations, and nobody had any thought at the start of the Conference of forming a health organization"[2]. Nobody ever expected the establishment of a health organisation during the San Francisco Conference in 1945. However, the WHO could be seen as nothing more than the culmination of efforts at international health cooperation that had started almost a century before. Surely it was not the first attempt of dealing with health at the international level[3].

The newly created Organization was to some extent an amalgamation of a number of existing organisations that together represented a long history of international cooperation, dating from as early as 14th century[4]. They were the Office International d’Hygiene Publique (OIHP), which had been set up by the International Sanitary Convention in 1907; the League of Nations Health Organization created after the First World War (1920); and the Health Division of the Unites Nations Relief and Rehabilitation Administration (UNRRA), which was dealing with health activities in the aftermath of the Second World War (1943). There were also regional organisations, like the Pan American Sanitary Bureau (1923) and Le Conseil sanitaire, maritime et quarantinaire d’Egypte (1938).

Let's have a look at the steps which led to the constitution of the World Health Organization through a hundred years.

1.1.  International Sanitary Conferences

The first known efforts to create an international public health mechanism to fight epidemics of infectious diseases can be traced back to 1851. That year the first International Sanitary Conference was held in Paris, after the 1830 outbreak of cholera in Europe, which caused the death of thousand of people in different countries.

The objective of the Conference was very limited: to harmonise and reduce to a safe minimum the conflicting vexatious, and costly maritime quarantine requirements of different European nations, and especially those with Mediterranean ports[5]. Such requirements originally concerned just the possibility of the importation of plague from Eastern Mediterranean countries. Later these measures were adopted against the appearance of yellow fever and later against the first invasion of cholera. Plague, yellow fever and cholera[6] were to remain until 1926 the only three diseases to be subject to International Sanitary Conventions[7]. Austria, France, Great Britain, Greece, Portugal, Russia, Spain, Turkey and four Sovereign States that were later to form Italy – The Kingdom of Sardinia and of the Two Sicilies, The Papal State and Tuscany - took part to the 1851 Conference. The first attempt of creating an International Sanitary Convention failed at this time.

The world had to wait till 1892 to see the first International Sanitary Convention to be agreed, signed and ratified, at the seventh International Sanitary Conference in Venice. It concerned measures for quarantine and hygiene practices restrictively for cholera. In 1893 and 1894, two further conferences on cholera were held. In 1897, a conference in Venice was held concerning the problem of prevention and diffusion of plague.

A total of four Conventions were eventually agreed upon and consolidated at the 11th International Sanitary Conference in 1903.

1.2.  Office International d’Hygiene Publique

The 1903 Conference led to a step of fundamental importance. It was agreed in principle that a permanent international health bureau should be established. This permanent organisation should maintain and report epidemiological data and coordinated quarantine measures.

As a result of this request, the Office International d’Hygiene Publique was created by the Rome Agreement of 1907 with headquarters in Paris[8]. It was composed by a permanent secretariat and a permanent committee of senior public health officials from twelve Member States, nine of which were European[9].

The decision to create such a permanent bureau was probably due to the fact that the American republics had already joined forces to establish in 1902 in Washington the International Sanitary Bureau[10]. The committee met towards the end of 1908 and thereafter twice a year, except for an interruption of five years caused by the First World War.

The OIHP did the preparatory work, for the next International Sanitary Conference in Paris in 1911–1912. The Conference resulted in the International Sanitary Convention of 1912, which did not come into force till after the First World War. The OIHP also prepared the next International Sanitary Conference, which took place in 1926, relatively to provisions against smallpox and typhus.

The last International Sanitary Conference was held in Paris in 1938 with a very limited scope. A Health Council of international composition located in Alexandria, in Egypt – one of the four regional public health bodies constituted in the nineteenth century for regulating quarantine procedures in the Mediterranean area was handed over to the Government of Egypt[11]. The Council became later known as Le Conseil sanitaire, maritime et quarantinaire d’Egypte, based at Alexandria[12].

1.3.  Health Organization of the League of Nations

A consequence of the First World War was a general desire to create an apparatus to build a better world. That apparatus took the form of the League of Nations, one of the task of which was to "endeavour to take the steps in matters of international concern for the prevention and control of disease".

The Health Organization of the League of Nations was therefore founded in 1920. The founders believed that its role should be more into the outbreaking of diseases as typhus and influenza following the First World War. They also established that all the existing international bureaux should be placed under the direction of the League, including the Office International d’Hygiene Publique. However, at the last moment, the USA, which was a member of the OIHP and not of the League, opposed its veto to such a fusion.

Thus, two international health organisations existed between the two World Wars in Europe – the OIHP and the Health Organization of the League of Nations. The other side of the Atlantic saw the creation of regional intergovernmental organisations, above all the International Sanitary Bureau of the Americas, formed by the governments of America in 1902. Renamed the Pan American Sanitary Bureau (PASB) in 1923, it was the forerunner of the Pan American Health Organization, which became one of the six Regional Office of the WHO after the Second World War[13]. The PASB was characterised by an active operational role, besides its basic function of collecting epidemiological data and exchanging such information. This balance between information-based and operational activities would later set the organisation apart from other WHO Regional Offices[14].

Three international health organisations dominated the scene, and consultative and cooperative arrangements existed between all three organisations. In particular, the Health Organization of the League of Nations started new approaches in the international health cooperation. It expanded its interest from nutrition to cancer and housing, it established committees of experts acting in a personal capacity, which is one of the main feature of current WHO work, it designated outstanding research centres to carry out international responsibilities on behalf of the League[15].

With the outbreak of the Second World War, international health work slowed down and came almost to a standstill.

1.4.  The Technical Preparatory Committee and the International Health Conference of 1946

Since the destruction caused by the Second World War, world leaders agreed to convene a Conference on International Organizations in San Francisco in 1945. This Conference represented an indirect occasion to discuss the creation of a truly international health organisation as part of the newly created United Nations system. "Why don't we start a new health organisation?" said Dr. Karl Evang of Norway, during a 'medical lunch' with Szeming Sze of China and Dr Geraldo de Paula of Brazil. "It must have been about 2 May 1945 […] I was a little sceptical because we had been asked to go to San Francisco to draw up the Charter of the United Nations, and I knew that there had been no thought beforehand of setting up a health organization. But Evang was so enthusiastic, as was his nature, that all three of us became keen to start something"[16].

Thus, the idea for a United Nations specialised agency for health was not initially included in the Charter agreed on at the United Nations Conference on International Organization, which was held in San Francisco in 1945. It was only following strong support by the Brazilian and Chinese delegations, who argued that "medicine is one of the pillars of peace", that a declaration was issued at the Conference recognizing health as a field which the United Nations should be involved with[17].

The procedure, which led to the constitution of an international health organisation, was not so easy as it could seem. "China was one of the four sponsors of the San Francisco Conference, along with UK, USA and USSR; so Dr Evang thought the Chinese delegation should take the lead in making the proposal […] I realized what was happening, I was landed with the job of presenting a proposal to the San Francisco Conference that we should set up a single health organization […] trying to tidy up the situation and pulling all these disparate organization into a single entity"[18]. How did it happen? "At first we thought the simplest way would be to propose a resolution, asking the Conference to draw attention to the situation and to convene another Conference in order to set up a single world health organization. But after a week or so the Steering Committee said that the Conference had too many draft resolutions to deal with, and delegations were asked not to submit anymore. We were disappointed and Dr Souza said 'why don't we try another route, by proposing that the word 'health' be inserted into the Charter?'. We thought that if we got the word 'health' in once, there would be an obligation to set up a health organization"[19]. The Brazilian delegation reached its aim, and the world 'health' appears in the UN charter, but the required Conference was not convened. "I was just giving up the hope of getting anything started when Fate took a hand: one evening at a dinner party I found myself sitting next to the Secretary-General of the Conference, Mr Alger Hiss. I asked him what we could do to provoke the attention of the Conference now that we could no longer present a resolution for its adoption. He immediately said 'Oh, it's very simple: don't present it as a resolution, call it a declaration'. It worked very well. We presented a recommendation for a general Conference to be convened to establish an international health organization, as a joint declaration by the governments of China and Brazil, that is, the delegation of Dr Souza and myself. Our declaration was approved unanimously by the Conference: that was the very beginning of the World Health Organization"[20].

At this point, in February 1946, the United Nations Economic and Social Council agreed that an International Health Conference would be convened in New York. The aim was "to consider the scope of, and the appropriate machinery for, international action in the field of public health and proposals for the establishment of a single international health organization of the United Nations"[21].

The Conference was prepared by a Technical Preparatory Committee, consisting of 16 experts in the field of international health – ministers of health or senior public health officials in their respective countries - and chaired by Dr Rene Sand of Belgium. The committee met in Paris during March-April 1946 to prepare an annotated agenda and proposals for the consideration of the conference. This work was also assisted by detailed proposals of individual delegates from UK, USA and France, serving in a personal capacity and by statements from existing health organisations, on the constitution of the new organisation. The Committee prepared a solution relatively to the new organisation's governing structure, administration, finance, mandate and even title.

The International Health Conference finally opened up in June 1946, and it lasted for six weeks from 19 June to 22 July 1946. It was attended by 51 member states of the United Nations as well as 13 non member states, the Allied Control Authorities for Germany, Japan and Korea, observers from relevant UN organisations and national health organisations. Delegations agreed on the constitution of the new organisation, a protocol for the termination of the OIHP, and the setting up of an Interim Commission to assume its duties as well as those of the League of Nations and the temporary United Nations Relief and Rehabilitation Administration (UNRRA)[22].

1.5.  The World Health Organization

Although the Constitution of the World Health Organization[23] was approved at the International Health Conference of 1946, it came into force on 7 April 1948[24], when the 26th of the 61 member states ratified its signature[25] and it deposited its formal instrument of acceptance with the Secretary-General of the United Nations. This date 7 April 1948 is considered to be the date of birth of the WHO[26].

During the Conference, it was decided that an Interim Commission should be created, until the Constitution came to formal effect to undertake the more pressing of the functions which would fall to the WHO, as soon as it was formally established. It had "to ensure continuity of certain health work and to make all the necessary preparations, as it was clear that some time would be needed for the countries that had signed the Constitution to ratify it and allow the Organization to become operative"[27]. Basically it was in charge of continuing the work undertaken by the OIHP and the Health Organization of the League of Nations. Furthermore, the Interim Commission assumed the responsibility of the Health Division of the United Nations Relief and Rehabilitation Administration (UNRRA), concerning the international sanitary conventions, the international epidemiological reporting and the work of medical relief.

The Interim Commission held five sessions, in Geneva. The choice of the exact location of the meetings was left to the Chairman, Dr Andrija Stampar of Yugoslavia[28]. At the last meeting, the Interim Commission prepared an agenda and a proposed programme of work for the first World Health Assembly, the plenary and legislative body of the World Health Organization. The first World Health Assembly opened up in Geneva on 24 June 1948 with delegations from 53 of the 55 governments that appear as WHO members at that time. The main decision was that the Interim Commission would not be existing by midnight on 31 August 1948 and that it would be succeeded on the following day by the WHO[29].

Following these steps, the WHO appears as the result of a long process, which led it to represent the single directing and coordinating authority in international health work. A unity was achieved through multiple and autonomous efforts.

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Edited by Aldo Campana,