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Decolonization, localization and WHO - History matters part 1
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In this episode we explore 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.
This is the first of our history matters episodes that we will bring to you during this season of Global Health Matters.
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Disclaimer: The views, information, or opinions expressed during the Global Health Matters podcast series are solely those of the individuals involved and do not necessarily represent those of TDR or the World Health Organization
All content © 2023 Global Health Matters.
Hello and welcome to the Global Health Matters Podcast. I'm your host, Gary Astranian. I'm so happy you tuned in for the third season of the podcast. I know it's hard to believe, but here we are. To kick this season off, I'm going to take a step back into the past and discuss the value and merits of understanding global health history. We will focus on narratives and explore the viewpoints and priorities that have shaped global health history, with a particular focus on the World Health Organization. My guests for this episode are two renowned scholars of global health history. Sanjoi Bachataria is the head of the School of History and Professor of Medical and Global Health Histories at the University of Leeds in the United Kingdom. Anne Manuel Byrne is Professor of Global Development Studies and of Global Health at the University of Toronto in Canada. Hi Sanjoy, hi Anne Emmanuel. Hi Gary. Hello, Gary. Welcome to the show. Let's get started. Sanjoy and Anne Manuel. Why does history matter?
SPEAKER_00So, Gary, history matters because for me it allows us a better understanding of how we've got here today and how we can function in better, more inclusive ways. All institutions have long histories, and those long histories have determined negotiations between complex partnerships, complex organizations, and how we operate today is deeply determined by those long-term negotiations, which is historical. So history matters. And Anne Manuel, what about you?
SPEAKER_01Yeah, just to build on that, I mean we can think about uh the role of history in four or five ways. Uh for those who are interested in uh particular places, institutions, professions, and so on. History is very important for building identity, knowing who you are, understanding, as Sandjoy has said, uh past trajectories. Uh, it's also very important at moments of reform or change. So when there is um uh a new policy or a uh more global change, such as the end of the Cold War, uh these uh moments become extremely important in which to kind of understand uh the what has gone come before and and what path might be charted uh into the future. It's also extremely important uh at moments of crisis, right? Um so at uh particular times uh when something changes quite suddenly, uh it helps us grapple with uncertainties. Um and then finally we can think about history as a kind of a window on society in general.
SPEAKER_02Could you please give us a brief overview of global health history and its key moments?
SPEAKER_01In terms of global health histories, I I think there are uh a number of germane points here. First of all, this is a relatively new term. Uh really uh in the 19th uh century, uh the arena that um has uh evolved uh or erupted, transformed into global health history uh began in a in a very particular context, that of imperialism, particularly European but also um North American um imperialism and uh the growth uh of the colonial enterprise. Health and medicine played a very important role. So uh one of the earliest precursors, if you will, to global health history was uh, or global health, was uh colonial medicine. Then there was kind of a shift to tropical medicine, and here uh the arena wasn't on tropical health, but rather it was kind of relabeled uh for uh the so-called tropical regions of the world, which actually overlapped in many ways uh with uh the parts of the world that had been colonized. In the 19th century, this new nomenclature of tropical medicine really had to do with this idea of creating something alien that was also a threat. And this was very much a fabrication. Uh, you had to create the notion of the tropics in order to have tropical medicine, uh, but also this idea that you know these parts of the world uh were threatening to Europe and to the imperial powers. So you have this whole uh recreation of uh then in the early 20th century you have a kind of a re-baptizing into international health. The idea here was in part drawing from the international sanitary conferences, but also trying to think about health across uh different parts of the world without um necessarily uh the uh colonial and uh imperial overlay. So you have this transition and it really takes off uh after the founding of uh the World Health Organization, this idea of international health, health between uh countries uh through um sometimes collective decision making, but also very much influenced by the world order, in that case, um, the Cold War. And then much more recently um you have this uh post-Cold War uh re-emerging of this idea of global health, which uh some argue is more or less a continuity of international health with um power asymmetries across different parts of the world. Uh others see it as an opportunity to highlight uh equity, inclusiveness, and really bring parts of what was formerly called the third world, maybe many use the global south, uh majority world, into decision making around uh health activities that affect uh arguably the entire globe, or certainly relations uh between and among countries.
SPEAKER_02We often approach lessons from the past with great confidence, and we want to apply this to our current contexts, to health situations and interventions. Are there any dangers in doing so?
SPEAKER_00So for me, you know, I mean, there isn't one historical narrative, and Emmanuel has just told us very powerfully. But I've always had a different view in the sense that when we are trying to fight for equity and trying to use history for equity, we are also then complicit in not listening to alternative voices, the resistance that has always existed from the time colonialism started to those dominant narratives, which empires tried to impose or uh organizations tried to impose. So there isn't one historical narrative. There is also the narrative of the colonizer, there is also the narrative of the resistor. This is where, for me, the study of history's implementation are very important. So the question you ask, Gary, for me is which history are we talking about? Are we talking about the history of the colonizer and the lessons of the colonizer? Are there dangers there in implementing? Absolutely. But then I would say that there are dangers in implementing elite histories and the radical histories that only look at the voices of the fewer as elitist, as let's say the history is being created by colonizing forces of whatever shape or size. But if we are looking at histories of implementation and complexity that use multiple voices to look at multiple experiences, there may be lessons to transfer over as long as we are aware that politics, economics, social determinants, and cultural determinants of health change from context to context. But dominant narratives written in metropolitan cities by us elite historians sitting in wonderful cities and wonderful universities, we have to work very hard to make that history applicable for policy implementation. Because we don't, we're part of the same elite group. We're just talking in different eco chambers. That's my take on it.
SPEAKER_01With the COVID-19 pandemic, uh there was an expectation in certain quarters that history would help to address, uh, resolve, uh shed light on the course of the pandemic, and so on. Uh so just kind of a first general comment, uh, I completely agree with Sandjoy that history is unable to make any kind of accurate prediction and uh arguably even provide comfort amid vicissitudes, solitudes, divided experiences of the pandemic. And there's no way uh historical perspectives can resolve social, political, and other forms of tensions that the response to COVID-19 continues to engender, arguably. History can't predict or uh liberate, uh, and every pandemic has occurred in particular social, political, cultural configurations. So there's no recipe, right? The expectation was that history would provide a recipe. Now that said, the the historical voices that garnered uh an enormous amount of attention were those uh based on uh European and North American experiences of plague, of uh influenza, and so on. And it became uh rather challenging for historians working from other perspectives, other parts of the world, uh to at least at a kind of a global uh level, to try and um intercede in those discussions. And so you have all of these false stories about what was going to play out based on the particular experiences uh of say uh Britain or uh Germany or the United States and so on. And one of the problems with this uh these attempts at kind of universalizing how pandemics start and end and you know what they're what the arc uh or the drama uh of how they unfold is, that it gives fuel to continued um flawed uh approaches and beliefs about pandemics today. So there's uh you know a very uh troubling um uh uh utterance, shall I say, of Melinda Gates very early on in the pandemic when Guayaquil was facing a terrible crisis, uh insufficient coffins, for example, uh, and uh bodies were literally lined up in the street. However, Melinda Gates then said, You see what's happened in Guayaquil with bodies lined in the streets, that the exact same thing is gonna happen in Africa, right? And she went on to say, you know, this is what we're facing in the rest of the world. And this was a very uh kind of recipe approach, imperial approach to understanding uh the pandemic without any kind of idea of what was going on. Actually, in many ways, Sub-Saharan Africa was uh the most important protagonist, the uh role of the um African Africa CDC, for example, in creating a shared platform for purchasing uh PPE, for um buying testing kits and so on. So, all this to say that we need to understand uh pandemics, uh, first of all, in their specificity, right? But also in terms of very different histories in different places and the kind of recipe assumptions uh that uh some of these grand historical narratives lent themselves to is very problematic.
SPEAKER_00There are multiple historical narratives about any aspect of global pandemics. So if you're saying, was COVID influenced by any historical narratives, I would say that one interest group that came up immediately and said, Oh, we have lessons to offer, were the polioeradicators, because they were saying, Oh, look, we've created all these structures for polioeradication, and we can give lessons and we can have these structures help, you know, COVID vaccine delivery and things like that. But the problem then became that there wasn't one historical narrative. There was a historical narrative sitting in Geneva, there was a historical narrative sitting in Seattle, and then if I use the example of India, there were multiple historical narratives sitting in India. But when that narrative was used to justify the polio eradication initiative's usefulness for what was happening in the COVID pandemic, what won through was a history of implementation, because that at the end of the day was what was actually useful on the ground. Not the big words being said in Seattle and Geneva, but actually the histories of implementation in India were then put to service. Those lessons and those experiences were put to service in relation to COVID and its vaccination against it. So again, my point is that there isn't one historical narrative. Every story has multiple historical narratives. We, as historians, can empower the voices of the elite. But when it matters in implementation, is the histories of implementation on the ground that often are more powerful than the big words said by elites who often don't know about context. So history matters, but we have to always ask which history is mattering, because there are multiple histories.
SPEAKER_02So, Sanjo, what about the history of WHO as an organization? And I think you've already alluded in your earlier uh response. How does the history of WHO as we know it and understand it today matter?
SPEAKER_00So for me, the WHO is not just Geneva. The WHO is equally all the regional offices. So when I look at the WHO, I don't just focus on the debates, discussions, and individuals who are saying things, doing things in Geneva. That is a very important part of the story. But for me, the history of the WHO is a mosaic. And if it's a 100-piece puzzle, 20 pieces of that puzzle is Geneva, the other pieces are the regional offices. So I then study what is happening at regional level. I see how normative policies suggested from Geneva are understood, negotiated, and then implemented at regional level. I'm not saying that the regions are free of elitism, but if you have a region, a bottom-up, a sort of region-up history of WHO, it becomes a very different history than what we often get published by leading Western presses, which then enter our uh educational system and then are taught in quite unquestioning ways. So if if you look at a bottom-up history of uh of the WHO where you center the regional offices, I would submit that you actually get a much more decolonized and democratic history of international and global health than you would if you looked at Geneva and say that everything that is happening in global or international health is happening because of things that are happening in Geneva. I submit they're not. I submit what is happening is much more in response to what is being discussed and negotiated at regional level. Okay, yeah, Anne-Emanuel.
SPEAKER_01I would actually go further than that. I think in some ways, only looking at the regional offices really uh takes away from uh what's going on in uh country by country and also alternatives to those regional offices. So if you look at uh settings like uh Brazil uh in the early 2000s, uh there was uh an attempt uh through the um Organization of South American States to actually create a different circuit that didn't have to go through WHO but could engage in health cooperation uh beyond WHO, but that ultimately influenced WHO. So it became a very important voting block, for example. And I think that some of uh Cuba's efforts, or many of Cuba's efforts in South-South cooperation, also are extremely important to look at. So understanding WHO is also understanding where WHO uh is absent. And those silences or those absences actually enable us to understand even more about how the organization, its regional offices and its national offices are not where all of the action is happening.
SPEAKER_02So if we were to explore um the history through certain achievements, umjo you had an article where you reflected on smallpox eradication and you highlighted uh unacknowledged role of, let's say, frontline health workers and communities. So, what kind of lessons can this history of implementation offer to current debates around how we improve global health and and including improve the work of the organizations involved?
SPEAKER_00So for me, Gary, technology is important, but the hands that hold the technology is far more important. So for me, technology isn't an answer for all the global health problems we face today. It's about developing the right human resources, it's about mobilizing the right teams, it's about making sure that those empowered teams have respectful and equitable connections with communities. If you get all of that in place, then I think the history of smallpox eradication, the way I see it, my historical narrative, there are lessons to be transferred over. And that lesson is simply this: that the thousand-odd USCDC officials who claim that they eradicated smallpox is a false narrative. Because, yes, I mean they went in and out of countries and did things, but they didn't implement stuff on a day-to-day basis over the many decades that were needed to eradicate smallpox. That work was done by hundreds of thousands of national workers and local workers, many of whom were women, many of whom did not speak English, many of whom wrote their reports and their analyses about how to improve things in languages other than English, and who were often forgotten by the chroniclers that the USCDC and the US government employed after smallpox was eradicated to write supposedly the definitive histories of smallpox eradication. So those frontline workers, for me, those let's say those 100,000 workers as compared to the 1,000 international workers were the real heroes and heroines of smallpox eradication because they taught the international and global fraternities about how to adapt some centrally developed ideas about how to do vaccination, who to talk to, what social determinants and what cultural determinants to consider. And many of these officials, we must remember, were paid by national excheckers. Their salaries were actually not paid by international bodies, they were paid by national excheckers. But when calculations were done about contributions to smallpox eradication, these national investments, huge national investments in smallpox eradication, are often not even considered in the figures when big claims are made about who contributed to smallpox eradication. So what I can tell Definitively, having looked at personnel files of many thousands of workers, none of them ever had their salaries paid for by USCDC in India. So at some point, we need to give the Indian government some credit for smallpox eradication as well. And that is what I meant by the unacknowledged actors, not just the workers on the ground, but people who were also paying salaries. The global south, I don't like that term, but if we talk in terms of low and middle-income countries and smallpox eradication, were not just a black hole in which high-income country money was being poured into so that smallpox could be eradicated. These countries were actually investing in the immunization frameworks that eradicated smallpox. They were equal partners in smallpox eradications. They were not beggars, they were equal contributors. And that is what I meant in that Lancet article.
SPEAKER_02Thank you for that. Anne Manuel, well, let's look at one other um historical event, which is the famous 1978 Almatta conference. That really still remains as a key kind of turning point. And actually, I was uh lucky enough to be at a 40 years of celebration of that conference, what is now called Almaty, actually. So, from your point of view, what does history of this conference reveal to us and how does it influence the current efforts uh around universal health coverage?
SPEAKER_01So, this is uh also a complex question. Uh, there are so many myths uh around the Almata conference and you know some of the tensions that Sanjay raised about who's telling the history using what kinds of sources and so on is uh a huge issue. I mean, it was uh only actually very recently, um, and I was uh in involved in in kind of trying to understand uh the backstory from the host country, which had never been examined. And that's still kind of a top-down history. But what were the interests of the Soviet authorities in uh hosting the conference? What were some of the tensions that arose? You know, what was the you know, famed uh Haftan Mahler's uh role, both in his support, but also his trepidation about not only the declaration itself, but having the event uh cited in the Soviet Union, what would that mean in the context of the Cold War and so on? Now, Almatin has served uh as a very uh important touchstone uh for many um health activists, right? And uh one in particular, and I consider myself a scholar activist, it has become um, you know, a very important way of reviving uh some of the aspirations that were articulated in the declaration around uh equity and the responsibility of national governments and uh the huge inequalities uh within, but especially between countries and so on. And these are all very important social justice issues. But I think it's also crucial not to overplay Almatta uh in multiple ways. First of all, you know, how much it was truly a turning point is a question mark in in part because what we just heard about the smallpox uh eradication, you know, the last uh six or seven years of that uh effort took place, were unfolding at the exact same time as the planning for Almat and so on. So that's one issue. Uh another is that um, you know, played out very differently in different regions. I mean, most countries, you know, raised their hand. There wasn't a formal vote, but a lot of acclamation for the declaration at the at the moment. But what that meant, uh, for example, in particular Latin American countries, um uh Brazil, uh uh Uruguay, uh, you know, Colombia, all these countries under either dictatorships or very repressive governments. And those governments said, yes, let's join the bandwagon and support almata. But for people on the ground, for health workers who are struggling for liberation, it actually uh meant uh primitive health care, right? Or health care on the cheap, not uh taking into account uh local needs and inequities within countries and so on. Uh on the other hand, in certain uh places, uh the exemplars uh that unfolded, uh Sri Lanka is one of those uh settings, Almata, was extremely important in Thailand as well. So you had it playing out very differently in different places, and lots of struggles also within um both within the WHO uh headquarters and regional offices, what it would mean. So the universal health coverage debate is also quite fraught, plays out very differently in different countries and uh between Geneva and um I should say Washington because the World Bank has been very involved. And one of the big issues has to do with whether it's universal health care or universal health coverage that is opening the door to private insurance, private players, and so on. So whether it's um uh really looking at a single tier of care under a public uh provider, um, under a public financer, or uh it's uh this very different kettle of fish as seems to be playing out. But again, uh we can see things that look quite different uh in different places. So I guess to be short on this question, is that there are real differences between aspirations and how things play out on the ground, and who are the array of actors, uh both locally, globally, within and beyond uh what we would call the global health sector that are influencing how this um gets implement implemented and taken up.
SPEAKER_02This year, 2023, is a historic year for the World Health Organization. The WHO is celebrating its 75th anniversary. You have written several papers on the factors that shaped and are shaping WHO. From your point of view, what are the prevailing current forces influencing the organization's current and future agenda?
SPEAKER_01Well, of course, WHO has been influenced by uh the larger global order, whether that's uh the Cold War and the fights that took place, uh the tensions over Al Mahata, over decolonization, uh, et cetera, et cetera. But it also played out in this era uh that I just referred to, the the rise of the neoliberal phase of capitalism, whereby uh some of uh the aspirations of WHO, its member states, uh sometimes in conjunction with UNICEF, to have um a list of essential medicines, for example, or a code of ethical uh conduct of um uh breast milk substitutes so that you you didn't have profiteering taking place in the in terms of technologies, pharmaceuticals, and so on. And so those uh that past has very much shaped uh the ways in which WHO has been able to respond in some of its uh points of maneuvering. So in the context of the um 1990s with the uh real constraining of WHO's budget, this meant turning to private players, philanthropic players, um, and so on. But this is also an era eventually of the rise of alternatives to WHO. I alluded before to South South cooperative efforts that are really bypassing WHO in large part because uh WHO has been under this uh yoke or choking of uh so-called earmarked funding, whereby the vast majority of its budget, some 80%, is actually decided by donors, whether that's um the larger countries uh or uh by pub public-private um uh partnerships, so private players, corporations, foundations, and so on. So I, you know, I think what when when we're looking at the future of WHO, we need to look at all of these actors and uh not only how they are shaping WHO's agenda, uh, but why in in the recent period these various alternatives to WHO have emerged precisely because of the constraints uh that have been placed on at least WHO headquarters, but in in many ways that uh also influences how regional offices uh are able to engage.
SPEAKER_02And Sanjo, you, as someone who has studied history of WHO and which two or three aspects from the organization's history should be used to continue to evolve and look into its future?
SPEAKER_00So when WHO was formally established in 1948, the body that helped it come into being was not just composed of people from high-income countries, but also from nationalist movements that were leading decolonization. So in 1948, for me, the WHO was a huge democratic force. It represented an active challenge to imperialism, it was an anti-imperialistic body of a type that had never been seen before, where all the countries that came out of the British Empire in South Asia had one vote each, which were equivalent to the single vote that Great Britain, the ex-colonial ruler, had. This was a seismic change in the way in which international health was going to be run. In this new model, the newly decolonized countries were important, a new type of regional office. The first regional office was the Southeast Asia Regional Office, it was important. And that is what excited me when DJ Tedros was elected, because DJ Tedros immediately said we need to engage countries more, we need to look at regional requirements more. So I think there is a connection between that very powerful initial history of the WHO when it was born for me as an anti-imperial force and the democratizing potential of some of DG Tedros's messaging today, where he constantly refers to the importance of country-level action. So I'm still waiting. There are just fantastic possibilities that I think the world needs to be brave and connect those histories with visions for democracy in the 21st century, and then connect those. I think there are great possibilities.
SPEAKER_02Thank you very much, both of you, Sanjoi and Anne Manuel, for this discussion today.
SPEAKER_01Thank you very much.
SPEAKER_02Thank you. The same is true for global health history. Personally, I was struck by the colonized lens Sanjo used to study the World Health Organization and the richness that emerged from understanding the events that occurred at country and regional levels. I felt that there was a lot of wisdom in Anne Manuel's words. For all of us who want to learn from the past, it's important not to view history as a recipe that can be directly applied in the present or in the future without the due consideration of context and culture in which these events took place. On this 75th anniversary, I want to express my congratulations to all colleagues working at WHO at different capacities and in different countries. For me, WHO and its history means a demonstration of what is possible when nations come together for a common purpose. Our future depends on how we strive for equity by bringing science, research, innovation, and partnerships together. If WHO didn't exist, we would need to invent it.
SPEAKER_03I enjoy listening to Global Health Matters because I like the perspective that Gary takes in interviewing his guests. My favorite topic episode was uh the discussion on decolonizing global health with uh Kathleen Chioktubungi and Prof Agnes Binagwaho. Um but it every topic is interesting and I make a point of listening to every new episode when it's released. Gary, thank you for this excellent podcast.
SPEAKER_02Thank you, Eberia, for sending such a positive message and for being such a loyal listener. To learn more about the topic discussed in this episode, visit the episode webpage where you will find additional readings, show notes, and translations. Don't forget to get in touch with us via social media, email, and by sharing a voice message with your reflections on how this episode and why you think that Global Health Matters.
SPEAKER_04Global Health Matters is produced by TDR, a research program based at the World Health Organization. Gary Aslanyan is the host and the executive producer. Lindy van Nieker, Maki Kitamura, and Obadiah George are content and technical producers. The podcast editing, dissemination web and social media design are made possible through the work of Chris Cole, Elisabetta Debi, Isabella Tudodao, and Chembe Collaborative. The goal of Global Health Matters is to produce a forum for sharing perspectives on key issues affecting global health. Send us your comments and suggestions by email or voice message to Tbrpod at WHO.int and be sure to download and subscribe wherever you get your podcasts. Thank you for listening.
