Palgrave Macmillan Journals Review Author(s): Myron E. Wegman Review by: Myron E. Wegman Source: Journal of Public Health Policy, Vol. 19, No. 1 (1998), pp. 106-110 Published by: Palgrave Macmillan Journals Stable URL: http://www.jstor.org/stable/3343092 Accessed: 16-10-2015 03:41 UTC

Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at http://www.jstor.org/page/ info/about/policies/terms.jsp JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact [email protected].

Palgrave Macmillan Journals is collaborating with JSTOR to digitize, preserve and extend access to Journal of Public Health Policy.

http://www.jstor.org

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions

Book Reviews JavedSiddiqi.WorldHealth and WorldPolitics:The WorldHealth Organizationand the UN System.Columbus,SouthCarolina:Univ. of SouthCarolinaPress,I995. XiV+z7z pp. $34.95 cloth. At the organizingmeetingthat createdthe UnitedNations (UN) in resolutioncalled for conveningan I945, a joint BrazilianlChinese International Health Conference. Multinational interchange in healthhad, in fact, datedbackto the mid-igth century,but emphasis had beenon internationalquarantineandhow it interferedwith commerce. Quarantine problems led to a series of I4 International Sanitary Conferences, beginning in I 8 5 I, and to establishment of the Pan American Sanitary Bureau (PASB)in i90z, the Office Internationale d'Hygiene Publique (OIHP) in I907, and the Health Organization of the League of Nations (HOLN) in i920. Thenin I946 came the conference that organized the World Health Organization (WHO) as the first truly comprehensive, worldwide body dealing with public health. Through relationship to the UN, links were created with an array of specialized agencies, opening a whole new chapter in international relations. Javed Siddiqi, a physician born in Pakistan, who was brought up in Canada and received a Ph.D. in international relations from Oxford, is now an assistant professor of the history of medicine at the University of Western Ontario. He has produced an informative and extensively documented book on the political aspects of WHO, aimed at assessing the effectiveness of the Organization. He uses political science parameters to measure WHO's accomplishments, both in its overall program and a specific component, the major worldwide program aimed at eradicating malaria. As one who for many years taught a course on the functioning of WHO that laid great emphasis on the political side, I would have welcomed Siddiqi's text as a basic one for the course. He covers a great deal of ground and keeps the focus on health aspects while elucidating organizational problems and relationships. The book is divided into four major sections: I, Effectiveness and Politicization, the Framework for Analysis; II, Attempts to Build a io6

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions

BOOK

REVIEWS

I07

Decentralized,UniversalHealth Organization;III,A Case Study:The MalariaEradicationProgram;and IV,Summaryand Conclusions. Siddiqibegins by illustratingthe kind of politicizationdecriedby many as extraneousto the tasks of WHO but upheld by others as directlyrelatedto the largerquestionof health.Underthis rubriche discussesmatterslike the US trade embargoon Nicaraguaand the relationshipof nucleardisarmamentto health. After this there is a sketchy history of the antecedentsof WHO and chapterson Effectiveness, its Meaning and Measurement;FactorsInfluencingEffectiveness;and Functionalismand Effectiveness.Much of this discussion deals with theory in internationalrelations and I had some difficultyin following the various arguments.One example of this difficultyis the sentencethat closes the historicalreview:"Despitethe relativesuccessof the LeagueHealth Organization... the difficulties with regardto amalgamationof the OIHPwereanythingbutpolitical." It is probablytrue that HOLN did not face questionsof nuclear war and trade embargoes, but surely the proposed amalgamation came a cropper over political rivalries among the major powers ratherthan technicaldifferencesover how to control diseasespread. PartII of the book goes at great lengthinto many of the questions concerningregional organizationsand the efforts to bring program decision-makingcloserto those directlyaffected.Siddiqidrawsheavily on an earlierwork by Berkov,publishedin I957 when the debate over regionalauthoritywithinWHO was still verylively.Siddiqi,like Berkov,highlightsthe region of the Americas,the prior existenceof the PanAmericanSanitaryBureau,and the desireof the USA and the other Americanrepublicsto maintainan independentorganization. The countries of the region obviously benefitedfrom having their governmentscontributingindependentlyto both organizations,thus effectivelyincreasingthe internationalhealthprogramsin the region. Furthermore,while the assessmentpaid by the USA to WHO is limited to a maximumof z 5% of the budget,the USA continuesto pay 6o% of the regularPAHObudget. Sincethe WIHO/PAHO cooperativeagreementwas signedin I949, the PASBoperationhas been a successstory of two sponsors and a single unifiedprogram.An individualpost may be funded by either PAHO or WHO but the staff memberis often unawarewhich, since funding does not affect duties or responsibilities.The color of the paycheckmay be revealing:when I was Directorof EducationI was

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions

io8

JOURNAL

OF PUBLIC

HEALTH

POLICY

- VOL.

I9,

NO.

I

paid by WIHO,with a greencheck;whenI becameSecretary-General, the checkbecameyellow. Siddiqialso devotesconsiderablespaceand analysisto othertrouble spots, notably the anomalousposition of the EasternMediterraneanRegion, relatedto the intensepoliticalrivalryand the longtime unifiedoppositionof the Arabiccountriesto any dealingswith Israel,hardlyconsistentwith the principlesenunciatedin the preamble to the WHO constitution.Resolutionwas less happythan in the Americasas Israelfinallymovedto the EuropeanRegion.The intricaciesof the long strugglearewell reviewed,as areotherissuesof the effortto achieveuniversalmembership,suchas the representationof China, the divided countries-Germany,Korea and Vietnam-and denialof votingrightsto SouthAfrica. There is an inevitabledifficultyin having a book by a scholar studyingthe printedrecordreviewedby someonewho was a participant, even a small one, in the eventsthemselves.Perceptionsof the rationaleand motivationsof the principalactorsarelikelyto be substantiallydifferent.What is difficultto assessfrom the recordis the way the Director-General(DG), who is elected every five years by essentiallya political process, sets a patternof attitude and goals within the secretariat,influencing a multinationalstaff that is extremelydiversein background,approach,and methodsof operation. In my view,the firsttwo DGs, whom I knew and workedwith, were remarkablepersons,devotedto the decentralizationof operating authoritywhile maintainingstandard-settingand establishment of guidelinesas a headquartersresponsibility.Candau'ssuccessor, HalfdanMahler,also enjoyedthe confidenceof the secretariat.Siddiqi does not discussthe politicalaspectsof electionof the Director Generalor the influenceof foreignministriesin this decision. BrockChisholmthe firstDG, was a warm,human,understanding psychiatristwhose knowledgeof interpersonalrelationsinformedhis own strong commitmentto decentralization.He had been Deputy Ministerof Health of Canada,that is, the chief professionalin the Ministry,essentiallysimilarto the USA Surgeon-General at the time or the AssistantSecretaryfor Healthtoday.Chisholmwas Secretary of the InterimCommissionunderwhichWHO operatedfor the two years it took to get z6 countriesto ratifythe constitution,and was electedDG by the FirstWorldHealthAssemblyin I948. In I953 he was succeededby MarcolinoCandau,a Brazilianepidemiologistwith

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions

BOOK

REVIEWS

IO9

extensivefield experiencein eradicatingmosquitovectorsfrom rural Brazil. Candau served for zo years and did an outstandingjob of holdingthe organizationtogetherduringcrisesover universalitysuch as the Arab/Israeliconflict,the changein representationof China,the denialof voting rightsto SouthAfrica,and the existenceof two parts of Germany.One aspect of the period not touched upon by the authoris the effect of the McCarthywitch hunt on WHO personnel, and the deft way Chisholm and Candau handled the problem. I believethe world owes a debt of gratitudeto both these remarkable persons for their contributionto keeping politics at bay duringthe crucialyears of WHO growth. PartIIIof the book is devotedto a studyof the malariaeradication program (MEP) as a focus for political influence. Siddiqi assesses MEP as a failure,which it surelywas from the standpointof achieving both its stated goal-disappearance of a major scourge-and a "promised"collateral benefit, expansion of a country's corps of trainedpublic health workers. Reasons for the failure are carefully documented,with, of course, the advantageof hindsight. Perhapsmore attentionmighthave beengiven to comparisonwith two other eradicationprograms.Smallpoxeradicationhas been an outstandingsuccess,but in Siddiqi'slimiteddiscussionof smallpoxhe just lists the biologicaldifferencesbetweenthe two diseases,without going into the not inconsiderablepolitical problems faced by the smallpoxprogram.One majorconsideration,for example,has to do with who benefitsmost from eliminatinga particulardisease and how this considerationaffectsthe financingof the relevantprogram. Recent arguments about the ethics and expense of worldwide poliomyelitiseradicationraisesimilarpoints. Par IV of the book, Summaryand Conclusions,has chapterson Evolutionof InternationalPublicHealth Philosophyand the Essence of Politicizationand Effectiveness.Siddiqiinfersthat there has been a dramaticchange from concentrationon the "vertical"approach, i.e., campaign-orientedprograms,to the "horizontal,"buildingbasic public health organization.But the latterclearlyhad the lion's share of expendituresas far back as the I950S. Similarly,Siddiqicites I964 and I965 WHO publicationson ways to utilize mass campaignsto advancebasic healthprograms,yet refersto this as a new approach. On the whole, this is a very useful book. Differencesof interpretation of past eventsare inevitable,but need not detractfrom the valid-

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions

110

JOURNAL

OF PUBLIC

HEALTH

POLICY

* VOL.

19,

NO.

I

ity of the basicthesisthat politicsand politicalinfluenceplay a large role on the world healthscene.An analogywith bridgebuildinghas long beencited as a crucialrole for healthin internationalrelations, both in the way politicsaffectsachievementof worldwidegoals and the way cooperationin health efforts affects generalinternational understanding.Siddiqi's book contributes to appreciatingboth effects. MYRON

E. WEGMAN

Pat Armstrongand Hugh Armstrong.WastingAway: The Undermining of Canadian Health Care. Toronto, New York, Oxford: Oxford University Press, I996.

Vi+245

pp.

$19.95

paper.

Canada'smedicaresystem has been highly successfulat achieving near-equityin accessto medicalcare,but sinceits inceptiontherehas privatebeen ongoingdebateon the relativemeritsof fee-for-service practicemedicineversuscommunityclinicsstaffedby salarieddoctors. Doctorsstill have an enormousamountof powereven in a changing system;while directpaymentto doctorsaccountsfor about 15% of the health care budget,doctors determinehow 8o% of the dollars will be spent. Consequently,the role of non-physicianprovidershas to date been restricted,with few being directlyreimbursedfor services providedoutsidethe hospital;most, suchas physicaltherapists and psychologists,aresalariedhospitalemployees.Inclusionof alternativeand complementarymedicinehas beenproblematic.Hospitalbasedcarehas accountedfor a hugeshareof expenditures(as it does in most health care systems),furtherskewed by the fact that many alliedhealthservices,and most prescriptions,arecoveredonly on an inpatient basis. Community-basedcare has been un- or underfunded,to the dismayof communityhealthadvocates.Andthe social determinantsof healthhave beenlargelyignored. Progressivepublichealthadvocateshave long understoodthe limitationsof nationalhealthinsuranceprogramssuch as Canada's;the news, in Canada,is just how successfullythis discoursehas been hijackedby deficit-hawkbudget-cuttersin recentyears. It's simply not good enough,in Canadain the I99Os, to recountthe social-deter-

This content downloaded from 155.69.24.171 on Fri, 16 Oct 2015 03:41:05 UTC All use subject to JSTOR Terms and Conditions