The globalization of public health: the first 100 years of international health diplomacy
David P. Fidler1
Abstract Global threats to public health in the 19th century sparked the development of international health diplomacy. Many international regimes on public health issues were created between the mid-19th and mid-20th centuries. The present article analyses the global risks in this field and the international legal responses to them between 1851 and 1951, and explores the lessons from the first century of international health diplomacy of relevance to contemporary efforts to deal with the globalization of public health.
Keywords Public health administration/history; World health/trends; International cooperation/history; Diplomacy; Communicable disease control/history; Drug and narcotic control/history; Employment/standards; Alcoholic beverages/supply and distribution; Water pollution/prevention and control; International law; Treaties (source: MeSH).
Mots clés Administration santé publique/histoire; Santé mondiale/orientations; Coopération internationale/histoire; Diplomatie; Lutte contre maladie contagieuse/histoire; Contrôle drogues et stupéfiants/histoire; Emploi/normes; Boissons alcoolisées/ressources et distribution; Pollution eau/prévention et contrôle; Droit international; Traités (source: INSERM).
Palabras clave Administración en salud pública/historia; Salud mundial/tendencias; Cooperación internacional/ historia; Diplomacia; Control de enfermedades transmisibles/historia; Control de medicamentos y narcóticos/historia; Empleo/normas; Bebidas alcohólicas/provisión y distribución; Contaminación del agua/prevención y control; Derecho internacional; Tratados (fuente BIREME).
Contemporary analyses of public health make much of its globalization and the national and international impact of this. Commentators argue that globalization creates challenges for the governance of global health, including the need to construct international regimes capable of responding to global threats to public health. These problems are not new: the globalization of public health led to the development of international health diplomacy and international regimes for public health beginning in the mid-19th century. This article analyses the first 100 years of international health diplomacy in order to elucidate what lessons the past holds for the governance of global health today and in the future.
The term "globalization" has been introduced only recently into analyses of world affairs. Most definitions of globalization indicate that it refers to the process of increasing interconnectedness between societies such that events in one part of the world increasingly have effects on peoples and societies far away (1). The idea that events in one part of the world have health effects in countries far away is familiar to historians. Thus McNeill analysed the formation of a Eurasian and then a global infectious disease pool from 500 BC to 1700 AD (2). The quarantine practices of European states in the 14th century marked the beginning of modern public health (3, 4). The history of public health is, in fact, that of the processes of increasing interconnectedness between societies such that events in one part of the world have health effects on peoples and countries far away.
International cooperation on the control of global risks to human health did not begin until the mid-19th century. Today's commentators argue that the factors accounting for globalization, such as information technology, trade and the flow of capital, undermine the state's control over what happens in its territory (5). Globalization forces individual states to cooperate with each other and build partnerships with non-state actors, such as multinational corporations and nongovernmental organizations, in order to develop global governance. Experts distinguish international governance, defined as intergovernmental cooperation, from global governance, which involves the interaction of states, international organizations, and non-state actors to shape values, policies and rules (6). In public health, the shift from national to global governance began in the mid-19th century, when international health diplomacy emerged because of concern about infectious diseases. During the next 100 years this facet of diplomacy expanded as states, international organizations, and non-state actors tackled global threats to public health through international law and institutions.
The public health risks that acquired global significance during this period were associated with infectious diseases, opium and alcohol, occupational hazards, and transboundary pollution. These matters are discussed below, as are the legal and institutional responses of states and international organizations; the role of non-state actors in global health governance from the mid-19th century until the mid-20th century; the effectiveness of the global health governance regimes constructed in this period; and the lessons of the first century of international health diplomacy for people currently struggling with global risks to public health and the politics they generate.
Global public health risks, 18511951
International health diplomacy began in 1851, when European states gathered for the first International Sanitary Conference to discuss cooperation on cholera, plague, and yellow fever (7). These states had previously dealt with transboundary disease transmission through national quarantine policies. The development of railways and the construction of faster ships were among the technological advances that increased pressure on national quarantine systems (8). However, disease control became a subject of diplomatic discussion as a result of the cholera epidemics that swept through Europe in the first half of the 19th century. National policies not only failed to prevent the spread of the disease but also created discontent among merchants, who bore the brunt of quarantine measures and urged their governments to take international action. In today's parlance, cholera was an emerging infectious disease that caught Europeans unprepared.
The next 100 years witnessed an evolution in international cooperation on infectious diseases. States convened conferences, adopted treaties, and created several international health organizations to facilitate cooperation on the control of infectious diseases. The work of Koch and Pasteur encouraged international cooperation as germ theory allowed diplomats to shape more informed policies and rules. By the end of 1951 this scientific and diplomatic process had produced the World Health Organization and a single set of international legal rules on infectious disease control, the International Sanitary Regulations (9). Over the course of a century, the global threat of infectious diseases had produced processes, rules, and institutions for global health governance.
International trade in narcotic drugs and alcohol
The international trade in opium was lucrative for the European powers. This was especially true for Great Britain, which forced China to allow the importation of opium from other British colonial territories, particularly India, after the Opium War of 183942 (10). Improvements in sailing technology, especially the development of the clipper ship, enabled the opium trade to expand, thus solidifying the economic links between Europe, the Americas, and Asia (10). International concern about the deleterious social and health effects of the opium trade grew during the latter half of the 19th century. The International Opium Commission held its first meeting in 1909 (11, 12). In response to the global health threat presented by narcotic drugs, states negotiated nine treaties on their control between 1912 and 1953.
The second half of the 19th century also saw Western states engaging in diplomacy about the adverse effects of alcohol on indigenous people in colonial areas. In 1884, Great Britain proposed that an international understanding be entered into for the protection of the indigenous peoples of the Pacific Ocean by prohibiting the supply of liquors to them (13, 14). Similar concerns found expression in the 1890 General Act of the Brussels Conference Relating to the African Slave Trade and in the 1899 Convention Respecting Liquor Traffic in Africa (15, 16).
Regulation of the alcohol trade to Africa continued into the 20th century. In 1901 the US Senate proposed that "the principle ... that native races should be protected against the destructive traffic in intoxicants should be extended to all uncivilized peoples by enactment of such laws and the making of such treaties as will effectually prohibit the sale by the signatory powers to aboriginal tribes and uncivilized races of opium and intoxicating beverages" (14). Using this resolution, in 1902 the USA proposed a universal treaty on limiting liquor sales "in the western Pacific, or in any other uncivilized quarter where the salutary principle of liquor restriction could be practically applied" (14). In the 1919 treaty regulating alcohol importation in most of sub-Saharan Africa, the signatories stated that the prohibition of alcohol importation was necessary because alcohol was "especially dangerous to the native populations by the nature of the products ... or by the opportunities which a low price affords for their extended use" (17). In addition, Western states exhibited concern about the illicit trade in alcohol among themselves, as evidenced by numerous regional and bilateral treaties.
Occupational safety and health
The industrial revolution that swept across Europe in the 19th century triggered concerns about health threats posed by dangerous working conditions. The mistreatment of workers by industrial enterprises became a global phenomenon that produced efforts to create international labour standards. Concerns about occupational safety and health continued into the 20th century and led to the creation of the International Labour Organisation (ILO) in 1919. The ILO's constitution emphasized the global nature of the threat to occupational safety and health, in asserting "conditions of labor exist involving such injustice, hardship, and privation to large numbers of people as to produce unrest so great that the peace and harmony of the world are imperiled; and an improvement in those conditions is urgently required" (18).
Transboundary water pollution
The industrial revolution created new environmental and health threats that transcended national boundaries and raised the need for international cooperation. Birnie & Boyle, analysing 19th-century and early 20th-century treaties regulating the uses of international rivers and lakes, observed that "early European practice frequently prohibited industrial or agricultural pollution harmful to river fisheries or domestic use" (19). Transboundary air pollution was the subject of the 1938 Trail Smelter Arbitration, whereby Canada was held responsible for damage caused in the USA by emissions from a Canadian smelting facility (20, 21). While not as geographically widespread as the problems presented by infectious diseases, transboundary pollution emerged in the 18511951 period as another public health threat that had to be tackled through international law.
International law, international institutions and global public health risks
Analyses of global public health risks have frequently mentioned international law and international organizations. When a state needs to cooperate with other countries to confront a threat, international law often becomes a central instrument in the crafting of a common approach. Globalization undermines a state's ability to control what happens in its own territory. Consequently, it is necessary to construct procedures, rules, and institutions through international law. Arguments about the importance of international legal regimes to the production of global "public goods" underscore the importance of international law in dealing with global problems (22). A great quantity and diversity of international legal regimes on global health risks emerged during the 18511951 period.
The series of International Sanitary Conferences that began in 1851 and continued for almost a century, together with other diplomatic efforts, produced many treaties on infectious disease control (Table 1). Also important to the development of international legal regimes on infectious diseases was the creation of international health organizations with a mandate to facilitate cooperation on infectious diseases. Four such organizations emerged during the 18511951 period: the Pan American Sanitary Bureau in 1902, the Office International de l'Hygiène Publique in 1907, the Health Organisation of the League of Nations in 1923, and WHO in 1948.a
International trade in narcotic drugs and alcohol
States also used treaties and international organizations to control international trade in opium and alcohol. The treaties on narcotic drug control that were negotiated between 1912 and 1953 are listed in Table 2. Advice on these treaties was provided by international health organizations, such as the Office International de l'Hygiène Publique and the Health Organisation of the League of Nations (8). The League of Nations created an Opium Advisory Committee in 1921, which examined international opium traffic (11). The Pan American Sanitary Bureau was involved in combating drug addiction in the Americas during the first half of the 20th cen- tury (23).
Treaties concerning alcohol sought to control illicit regional or bilateral traffic or to restrict the importation and sale of alcohol in Africa (Table 3 and Table 4). The 1919 treaty regulating alcohol traffic in Africa created a central bureau to oversee implementation under the authority of the League of Nations (17). The Health Organisation of the League of Nations began working on alcoholism in 1928 (24).
Occupational safety and health
States also turned to international law and international organizations in connection with the improvement of occupational safety and health standards (Table 5). The founding of the ILO in 1919 catalysed the creation of international labour law because this body adopted numerous treaties on the improvement of standards.
Transboundary air pollution
European and North American states used treaties to regulate pollution in international watercourses in the latter half of the 19th century and the first half of the 20th century (Table 6). The rules in the treaties were not uniform in their approach: some strictly prohibited pollution, while others tolerated pollution caused by reasonable uses of international watercourses (19). Treaties on transboundary air pollution did not, however, develop in the 18511951 period. The best-known international legal dispute on transboundary air pollution in this period, the Trail Smelter Arbitration (1938), involved the application of customary international law rather than a treaty. Nevertheless, it demonstrated that international law applied to transboundary air pollution. The arbitral panel held that "no state has the right to use or permit the use of its territory in such a manner as to cause injury by fumes in or to the territory or the properties or persons therein, when the case is of serious consequence and the injury is established by clear and convincing evidence" (20).
Non-state actors and the globalization of public health, 18511951
A feature of contemporary globalization is the growing importance of multinational corporations and nongovernmental organizations on both global health problems and global governance (25). The involvement of non-state actors in globalization largely distinguishes global governance from international governance. Between 1851 and 1951, merchants involved in moving people and goods around the world contributed to the spread of infectious diseases and to the international trade in opium and alcohol. Commercial enterprises, frustrated by national quarantine systems, exerted pressure on states to launch and sustain diplomacy on infectious disease control (26). Nongovernmental organizations, such as the Rockefeller Foundation and the International Union Against Tuberculosis, cooperated with international health organizations in tackling infectious diseases and other public health problems (8). The International Bureau Against Alcoholism, established in 1907, urged governments to limit alcohol imports, especially in Africa (24).
A major development came with the provision in the ILO constitution that delegations of Member States should all include representatives from industry and labour unions who should have the right to vote alongside but independently of government representatives (18). ILO is also empowered to receive representations from employers' and workers' organizations if they consider that a Member State is not complying with ILO treaties to which it is a party. This gives non-state actors an important role in monitoring international labour standards (18).
The growth in the importance of nongovernmental organizations in global health between 1851 and 1951 can be demonstrated by comparing the treaties establishing the Office International de l'Hygiène Publique and WHO. The 1907 treaty creating the Office International de l'Hygiène Publique contains no mention of nongovernmental organizations or of the possibility that it could collaborate with them (27). On the other hand, WHO's constitution provides that it can consult and cooperate with nongovernmental organizations (28). While not as robust as the ILO constitution in respect of the use of non-state actors, WHO's constitution recognizes the importance of publicprivate partnerships between international health organizations and nongovernmental organizations.
Effectiveness of global health governance regimes, 18511951
In general, the development of international legal regimes on matters of public health has been impressive. However, the mere enumeration of treaties does not give any indication of their influence on public health. Indeed, the treaties might even be seen as rearguard actions against advancing health risks generated by modernizing technologies and the processes of globalization.
Domestic sanitary and public health reforms were more significant than treaties in reducing morbidity and mortality attributable to infectious diseases in many Western countries during the first half of the 20th century (29). Doubts about the treaties were raised as early as 1894 by Koch, who criticized those targeting cholera as superfluous because the proper policy was for every country "to seize cholera by the throat and stamp it out" (7). In 1947 the US Department of State argued that many states were bound only by obsolete conventions or by no treaties at all (30). Experts believed that states were slow to adapt treaty regimes to changes in scientific knowledge and patterns of international trade (30, 31). The treaties were also not considered important in connection with public health law generally (32). Furthermore, the existence of multiple international health organizations complicated their efforts on infectious diseases and other issues (33).
Questions abound in connection with the international legal regimes established to deal with traffic in narcotic drugs and alcohol. Brewley-Taylor observed that "European nations were unwilling to surrender national sovereignty over domestic drug control or relinquish profitable opium monopolies in their colonies until the League [of Nations] was effectively dead" (12). While missionaries claimed that the 1890 treaty regulating alcohol sales in Africa "was to a good degree effective in the Congo region" (14), it is not clear whether this regime protected Africans from alcohol and the adverse consequences of its abuse. The USA initiated most of the bilateral treaties on illicit alcohol trade after its own unsuccessful prohibition of alcohol consumption in 1919. International legal analysis of the liquor treaties in the 1920s focused not on public health but on whether their enforcement conformed to the international law of the sea (34).
The efforts of ILO to improve standards for occupational safety and health were undermined by friction associated with its treaty-making, by the failure of ILO Member States to ratify or comply with treaties, and by the world economic depression (35). Industrial development continued to increase air and river pollution. The later treaties in this period relating to international rivers in Europe clearly showed increased tolerance of pollution as industrial demands on river resources continued to grow (19). In connection with transboundary air pollution, the precedent of the Trail Smelter Arbitration remained unique, indicating that such pollution became routine as industrialization spread around the world.
Conclusion: lessons for the contemporary globalization of public health
In the first 100 years of international health diplomacy, global health governance across a range of public health issues was attempted by states, international health organizations, and non-state actors An enormous body of international law on public health, now largely forgotten, was created. The following characteristics marked this period of global health governance: 1) a tendency for health risks to become global because of the growth in international commerce; 2) a need for states to cooperate through international law in order to confront global threats to health; 3) the involvement of nongovernmental organizations and multinational corporations; and 4) mixed results achieved by international legal regimes.
In contemporary discourse about the globalization of public health, experts emphasize the global nature of public health threats, e.g. those associated with pathogenic microbes and the trade in tobacco products. Similarly, calls for international cooperation and legal action against global health risks abound. WHO is revising the International Health Regulations (36) and leading the negotiation of the Framework Convention on Tobacco Control (37). Experts have called for international agreements on alcohol control (38), the rights of the mentally ill (39), the funding of global vaccine supplies (40), pandemic influenza vaccine supplies (41), and the improvement of access to essential drugs and vaccines (42). Increased prominence is being given to international law in the field of public health (31, 43, 44). Experts stress the importance of participation by non-state actors in matters of global public health (45). In terms of global health governance, history appears to be repeating itself .
However, the 18511951 period teaches us to be realistic about what states, international health organizations, and non-state actors can accomplish using international law as a means of dealing with global health problems. Earlier experience in the construction and revision of international legal regimes relating to public health serves as a warning in connection with WHO's efforts to revise the International Health Regulations and create the Framework Convention on Tobacco Control. WHO Member States rejected innovative changes to the International Health Regulations proposed in 1998, e.g. those relating to syndromic reporting and the establishment of a committee of arbitration to deal with violations of the rules (46). What form the revised International Health Regulations will take remains unclear. The content of the Framework Convention on Tobacco Control has yet to be agreed among states (47). The history of efforts to achieve international control of narcotic drugs and alcohol suggests that an effective treaty on tobacco control will be difficult to achieve.
The 18511951 period of global health governance exhibits the same paradox as has been identified by the contemporary analysis of the globalization of public health: globalization jeopardizes disease control nationally by eroding sovereignty, while the assertion of national sovereignty can frustrate disease control internationally (48). The first 100 years of international health diplomacy proved how vulnerable global health governance was to the machinations of states and the volatile dynamics of international politics. Economic and technological interconnectedness in the period caused public health risks to become global more effectively than they fostered international cooperation to control them. Furthermore, the behaviour of the great powers undermined global health governance. Imperialism, two world wars, and a global economic depression weakened international cooperation on public health. The efforts of Western states to regulate the Asian opium trade and the trafficking of liquor to Africa seem hypocritical when one considers the exploitation of Asians and Africans at the hands of these countries.
Current concerns about global health threats from infectious diseases, narcotic drugs, alcohol, tobacco, labour standards, and environmental pollution suggest that global health governance still lags behind the ability of human societies to create and spread disease. The revision of the International Health Regulations and the work on the Framework Convention for Tobacco Control mirror the pattern seen in the 18511951 period. Efforts in global health governance are belated reactions to developing and established epidemics, reducing the prospects for successful international cooperation. Just as Great Britain forced China to accept the opium trade in the 19th century, the USA and other great powers spread the tobacco pandemic through their efforts to break into the markets of developing countries with cigarette imports. The myopic approach of the great powers has also been evident in the controversies surrounding access to essential drugs and medicines, e.g. HIV/ AIDS therapies, in the developing world. Contemporary global health governance is vulnerable to the machinations of the great powers and the resentments of those who remain alienated by international politics.
Global health governance in the 21st century faces problems not seen in the first 100 years of international health diplomacy, e.g. those relating to genetic engineering and access to essential drugs. New technologies, such as the Internet, provide non- state actors with more powerful resources with which to influence the direction of global health governance. For these and other reasons, looking backwards can offer lessons of only limited value. States, international health organizations, and non-state actors confront such 21st-century challenges with tools of global health governance that have remained largely unchanged since the 19th and early 20th cen- turies. This suggests that, in the final analysis, the tools are unlikely to bring about the differences that are needed. These are more likely to be achieved if states internalize public health effectively as an interest and value. Towards the end of the 1851 1951 period, the WHO constitution envisioned health as a fundamental human right. This is a far cry from the scientifically ignorant, selfish national fears that drove public health on to the diplomatic agenda in the mid-19th century. Contemporary angst about global public health reveals that WHO's vision remains unfulfilled after more than 50 years of the organization's existence. Today, it is vital that human societies should move closer to fulfilling this vision instead of remaining trapped in the patterns established between 1851 and 1951.
Conflicts of interest: none declared.
La mondialisation de la santé publique : les cent premières années de la diplomatie sanitaire internationale
Ce sont les menaces qui pesaient sur la santé publique dans le monde au XIXe siècle qui ont suscité l'apparition d'une diplomatie sanitaire internationale. De nombreux régimes internationaux applicables à la santé publique ont été instaurés entre le milieu du XIXe et le milieu du XXe siècle. Le présent article analyse les risques mondiaux dans ce domaine et l'ensemble de dispositions légales mises en place pour y faire face au niveau international entre 1851 et 1951, ainsi que les éléments de la diplomatie sanitaire internationale dont pourraient s'inspirer les efforts déployés actuellement face à la mondialisation de la santé publique.
Globalización de la salud pública: los primeros 100 años de la diplomacia sanitaria internacional
Las amenazas mundiales que se cernieron sobre la salud pública en el siglo XIX dispararon el desarrollo de la diplomacia sanitaria internacional. Numerosas pautas internacionales sobre cuestiones de salud pública se establecieron entre mediados del siglo XIX y mediados del siglo XX. En el presente artículo se analizan los riesgos mundiales en este campo y las respuestas jurídicas internacionales articuladas contra ellos entre 1851 y 1951, y se examinan las lecciones de la diplomacia sanitaria internacional que más interés revisten para los esfuerzos actualmente desplegados a fin de abordar la globalización de la salud pública.
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