Medicine, Industry, and Empire: Tracing the Evolution of Global HealthBy GHHub
By Alyssa Botelho
Harvard College Global Health Review
It is difficult to imagine a line of work less contentious than that of global health. Undeniably benevolent and unabashedly idealistic, it is a field that draws admiration across lands near and far. Yet while global health enamors, the field also escapes definition. It is at once an effort dictated by the formal declarations of signatory nations, the missions of for-profit and non-profit organizations to cultivate health as a “global public good,” the struggles against epidemic disease, natural disasters, bioterrorist threats, and the preservation of market capitalism in today’s world economic order. As these myriad efforts are difficult to synthesize, their origins are also difficult to trace: global health refuses to present an obvious development from the medicine of varied locales.
Though global health’s history remains elusive, one aspect of its evolution is clear. As Dr. Jeremy Alan Greene, a History of Science professor at Harvard University and Associate Physician at Brigham & Women’s Hospital describes, “Global health was not buffered from the economic and political context of its time, but happened in concert with it.”
In this vein, Birn, Pillay, and Holtz explore the development of global health in their Textbook of International Health through “a political economy approach” that views health “in the context of the political, economic, and social structures of societies.” They argue that health is but one facet of “who owns what, who controls whom, and how these factors are shaped by and reflect the social and institutional [demographics].” In doing so, it becomes important to draw distinctions between the terms public health, international health, and finally, today’s global health. These are terms that can ultimately be explained from their historical origins by tracing health regulation from the 1300s to today’s most innovative health efforts.
Health’s Expansionist Eye: Colonial and Tropical Medicine
In order to understand the concerted evolution of global medicine, it becomes essential to ask why citizens—and their governments—became concerned with the spread of disease across borders in the first place. Of course, public sanitation efforts and theories of disease causation can be traced to the world’s earliest civilizations—from Rome to Mesoamerica to the Middle East. However, health regulation on a trans-continental scale first appeared during the Middle Ages with the Black Death. To this day, the bubonic plague remains the most destructive epidemic that man has faced—taking over 25 million lives throughout Europe and Asia. Indeed, it was the plague that prompted Venetians to enforce the first quarantine (a 40-day detention for ships entering their harbor) and religious orders throughout Europe to establish the first hospitals.
However, global health as it is known today is rooted in the health challenges that arose with the global expansion of European imperialism: colonial medicine. Nearly three hundred years before Western nations turned inward to scrutinize health reform during the Industrial Revolution, health regulation was firmly on the agendas of European conquerors. Medical practitioners often traveled as members of colonial conquests, many of whom attempted to control epidemics for Spanish conquistadors. Most often, their care entailed the protection of invading settlers and colonial profit at the expense of their indigenous neighbors, and later, of their slaves.
By the 1800s, health threats to colonizers increased as conquest deepened in “the tropics,” a term that did not simply describe middle-latitude territories, but an invented domain of the imperial powers. For white conquerors, “the tropics” was an alien world where “the familiar forms of temperate life were threatened, overturned, and inverted.”1 The health development that arose out of these Asian, African, and Caribbean territories is labeled today as tropical medicine. A classic case study in tropical medicine is the battle against malaria, a menace against European colonizers that halted the productivity of their plantation slaves and fueled the rise of bacteriological research. One pioneer in this effort was the British physician and parasitologist Patrick Manson, who not only researched the link between the malaria parasite and its mosquito vector, but also helped establish schools of tropical medicine in Britain to bolster the development of international cash crops (and recruit the laborers to harvest them). With the case of malaria being just one example, global health’s earliest efforts hark to a dark imperialistic history that tackled health concerns not out of benevolence or even of mutual benefit, but purely out of exploitation.
Looking Inward: The Rise of Public Health
As colonial ventures escalated in the mid-1700s, Europe was undergoing both an imperial and an internal transformation. The Industrial Revolution brought about a massive shift from feudalism to capitalism that prompted the English government to scrutinize the health of its own people. As the factory system and power-driven machinery made industry king, the standard of living in England’s urban centers plunged. Sanitation and city planning were virtually nonexistent, and cholera, tuberculosis, and
diphtheria were rampant. Suddenly, health reform emerged at the forefront of the domestic agenda in the establishment of modern public health, “a concept coined in the early 1800s to distinguish government efforts for the preservation and protection of health from private actions.”
Edwin Chadwick and Friedrich Engels were at the forefront of these public health agendas, though the two men supported divergent solutions. Chadwick, a British lawyer and civil servant, demanded improvement in public sanitation but did not work for labor reform, denying that “poverty itself was the cause of illness.”1 Engels took an opposing position, attributing the “cause of ill health to the exploitation of the industrial working class under the capitalist economic system.” These efforts would later shape his work with Karl Marx in the 1848 Communist Manifesto.
The birth of public health was not isolated to Britain alone. Similar social and labor movements appeared throughout Europe in the mid-1800s, including health reforms sparked by the founding of France’s Second Republic and the work of Rudolf Virchow in Prussia.
By the mid-1900s, the independent domains of colonial medicine and public health were drawn together in Europe’s fight against cholera, a disease that “would bridge the distance between colonial and metropolitan health.” It was an illness that raged both in the urban squalor of industrial Europe and the “tropical” colonies along the equator. Suddenly, the health concerns of imperialists and industrial capitalists merged in the development of international health. Though decades removed from the height of imperialism, the term reflected an interest “to protect international commerce and fend off epidemics of diseases, such as cholera and plague, that might cause social unrest or reduce worker productivity.” Determined to halt further cholera pandemics, national public health strategies were channeled into international efforts; one of the first was the 1851 International Sanitary Conference (coincidentally, the year of the first World’s Fair in London) that brought together 12 European states to combat cholera. Others quickly followed suit: among them was Jean Henri Dunant, who inspired the founding of the Red Cross in 1864, the founders of L’Office Internationale d’Hygiène Publique (OIHP), or the “Paris Office” in 1909, and the League of Nations Health Organization (LNHO) in 1920.
Instead of a colonial medicine that promoted blatant imperial repression, international health offered aid with an air of benevolence and an implicit interest in the expansion of global capitalism. The leader of this new effort was the Rockefeller Foundation, which likely coined the term “international health” itself. Established in 1913 by John D. Rockefeller, this philanthropic foundation carried out disease campaigns in countless countries and colonies and founded several American schools of public health. The foundation’s unique philanthropic independence allowed it to strategically fight diseases that were least costly, complex, and time-consuming: a model still used by global health organizations today.
The Rockefeller Foundation was just one member of a powerful team of public and private multilateral organizations, with the OIHP, the LNHO, and the Red Cross being just a few. Their work, a marriage of colonial medicine and public health, cannot be considered without acknowledging the simultaneous rise of imperialism and industrialization. Indeed, health is not a neutral domain; it is ingrained in a struggle for power and influence of one nation over the other, or of a state over its people. Today, we must wonder how global health diverges from this aim, if at all. As Greene explains, “It becomes important to understand the colonial basis that prefigured global health in order to engage with the consequence of current strategies and negotiate resistance.”
Contemporary Global Health
In their 2006 article, Brown et al. address the ambiguous shift from international health to what they term global “public” health, which was a synthesis of colonial medicine and public health sparked by the first multilateral organizations of the 1900s. They explain that the term global health supersedes the political and ideological charge of its predecessor to convey shared susceptibility in promoting health in a globalized era. This globalization, of course, cannot be limited to the transfer of money or manufactured goods, but must include migrating peoples and the diseases they carry with them. Birn et al. contend that this new term transcends the precedent of international health to “refer to the health needs of people across the world, irrespective of borders, thus depoliticizing the field.”
In the wake of the physical and economic destruction of Europe and Asia in World War II, a restructuring of enormous colonial blocs of power placed a great emphasis on international cooperation. In this new political landscape, an unprecedented network of international organizations appeared, with the most notable being the World Health Organization (WHO), the World Bank, and bilateral aid agencies in formal colonial powers.
The ratification of the WHO in 1948 consolidated the strategies and personnel of the Rockefeller Foundation and its contemporaries on an unprecedented level. Though the divided alliances of the Cold War were a hindrance, the decades following WWII were formative ones. In these years, the WHO initiated a worldwide immunization program, ensured the affordability of baseline medications, and directed groundbreaking vertical disease campaigns—the most notable being the eradication of smallpox from 1967 to 1980. In conjunction with the WHO, the World Bank directed the allocation of financial resources to allow countries to develop public health programs within their national borders.
Though the WHO and the World Bank are the giants of global health today, smaller bilateral organizations may be most reminiscent of global health’s imperialistic roots. Today’s developed nations provide targeted healthcare assistance to weaker allies to advance the home nation’s security and economic interests. The United States, with the United States Agency for International Development (USAID) as its flagship agency, remains the largest bilateral donor in the world today.
Alongside these forces, one cannot exclude the newest facets of global health network: the rise of for-profit pharmaceutical and insurance companies, public-private partnerships (PPPs), and innovative non-governmental organizations (NGOs). The influence of “big pharma” such as the Merck Company or the “corporate philanthropy” of Shell, Exxon, or even Nestlé, though concerning, is undeniable. The work of PPPs like the Global Fund to Fight AIDS or the Stop TB Partnership has bolstered the work (though not the autonomy) of the WHO. Finally, one must not forget the efforts of revolutionary NGOs like Oxfam, Doctors Without Borders, and Partners in Health, all of which bring explicit missions of social justice to their work abroad.
Only by tracing back to the quarantines of the bubonic plague can today’s incredibly varied arena of global health players be illuminated. However, unlike conquistadors or labor reformers, today’s health leaders must tackle the fragmentation and accountability of PPPs and NGOs, scrutinize the conflicting agendas of the public and private sectors, and maintain the bureaucratic efficiency of multilateral organizations. Nonetheless, their visions are fundamentally built upon those of their predecessors. Today’s efforts may not be so far removed from those of American colonizers, tropical bacteriologists, British social reformers, or of philanthropist-oil-tycoons after all. As Greene stresses, “Only with history can we begin to render the present unfamiliar, and approach global health with a keener sensitivity and patience.” Indeed, only with this purview can one truly realize that “the development of biomedicine, public health, and empire are far more interrelated than it first seems.”•