International cooperation in matters concerning health emerged as governments became alert to the threat of diseases being imported into their countries. In the 19^th century it was particularly cholera that led to an organized international response. The first International Sanitary Conference, held in 1851, developed a series of regulations concerning quarantines. These more or less remained in force during the subsequent conferences that were held later that century: Paris 1859, Constantinople 1866, Vienna 1874, Washington 1881, Rome 1885, Dresden 1893, Paris 1894 and Vienna 1897.

The United States, which had not participated in the earlier conferences, was responsible for convening the 1881 Washington conference. Invitations were sent to all countries “having jurisdiction of ports likely to be infected with yellow fever or cholera». The aim of the meeting was to secure an “international system of notification as to the actual sanitary conditions of ports… and of vessels sailing therefrom».

The need for an international health office had been aired but not acted on during the 1874 Vienna Conference. It was envisaged that such an office would collect and communicate information concerning epidemic diseases. This proposal was again repeated in 1902 at the International Conference on Public Health and Demography. In 1903 the 11^th International Sanitary Conference, held in Paris, adopted a resolution requesting the French Government to propose the creation of such an office. On December 9, 1907 twelve Governments signed an International Agreement for the establishment of the Office international d’hygiène publique (OIHP). A small office with permanent full-time staff was opened in Paris.

The Permanent Committee of the OIHP was composed of one technical representative of each participating state. Normally they met twice a year for about ten days. The 12^th Sanitary Conference, which took place in 1912, agreed to establish a more permanent forum for the administration of co-operation between states and the OIHP concerning health matters. This conference adopted a new convention in which it was recognized that humans might carry the cholera vibrio; it also made yellow fever a reportable disease.

While European countries established the OIHP, American states, following the 1880 meeting in Washington, took action to establish a comparable mechanism for their part of the world. This led in 1902 to the founding of the Pan-American Sanitary Bureau (PASB). Its charter, drawn up in Washington in 1905, focused on developing a common sanitary code and an intelligence service.

The OIHP lacked the authority to carry out medical relief. Instead it concentrated on improving the means available for exchanging information on five reportable diseases – plague, yellow fever, cholera, typhus and smallpox. It added specific information to be reported regularly, e.g. the number of rats destroyed in ports and on ships, the lists of ports possessing certain standards of sanitary equipment, and lists of sanitary aerodromes.

With the entrance of the Rockefeller Foundation into international health and stimulus provided by World War I to share knowledge and resources needed to combat infectious diseases, international health can be said to have truly arrived.

The Rockefeller Foundation

The Rockefeller Foundation was established in 1913, with John D Rockefeller Jr as its president. Its stated aim was to “promote the well-being of mankind throughout the world”. The Foundation’s trustees agreed that the work of the Foundation was not to provide charity or relief but instead to offer “the means or the occasion for evoking from the community its own recognition of the need to be met, its own will to meet that need, and its own resources, both material and spiritual, wherewith to meet it”. If they were to choose between “objects which are of an immediately remedial or alleviatory nature, such as asylums for the orphan, blind or cripples, and those which go to the root of individual or social ill-being and misery, the latter objects are preferred – not that the former are unworthy, but because the latter are more far-reaching in their effects”,

The Rockefeller family already had launched a program that met these criteria – the Sanitary Commission for the Eradication of Hookworm, an organization established in 1909 with Wickliffe Rose as its administrative secretary. Rose was not a medical doctor; he was a professor of philosophy at Peabody College and a Southerner from Tennessee. One month after the Foundation was established, an International Health Board (IHB) was created with Rose in charge. Soon thereafter, the China Medical Board (CMB) was established to oversee programs in China.

 

 

The extension of anti-hookworm efforts to other parts of the world emerged from a trip undertaken by Rose to London in August 1913, where agreement was reached with the British Colonial Office to initiate anti-hookworm campaigns in British Guiana and other areas of the British West Indies, followed by Egypt, Ceylon and the Malay States. After several trips abroad, a strategy was developed for a mass attack on hookworm infection, which eventually led to projects in 52 countries and 29 islands. Virtually all of the IHB staff, whose names appear in this book, started their careers in hookworm projects – John Grant in Puerto Rico and Santo Domingo, Lewis Hackett in Central America and Brazil, Victor Heiser in Ceylon, India and Australia, and Wilbur Sawyer in Australia. Gunn was an exception.

According to Hackett, hookworm was the “best” disease that Rose could have chosen as an entering wedge for a long-term public health program. It was superior to both malaria and yellow fever for there were “no mysteries about the nature of the hookworm or the way it spread.” And, it was large enough for the victims to see without a microscope. Furthermore, as the “promotional and educational aspects of hookworm control were subtle and difficult, calling for a leader experienced in methods of teaching and in the ways of the South,” there was no better man than Rose, a layman and “distinguished Southern educator,” to lead the effort.

The methods used in the hookworm campaigns evolved over time; mass treatment gave way to the improvement of sanitary conditions, with treatment limited to those sick individuals harboring dangerous levels of worms. While Rose entertained hopes of eradicating the disease, the results obtained argued otherwise. By 1920 the campaigns were in disarray. Local authorities failed to invest in improving sanitary conditions; only with rare exceptions did hookworm prove to be an “entering wedge” that led to the creation of some kind of local public health infrastructure.

A new division of Medical Education (DME) was established in 1919 with Richard Pearce in charge. Pearce was a professor of pathology and research medicine at the University of Pennsylvania before undertaking a survey of medicine in Brazil and becoming an adviser to the IHB in medical education. He was a protégé of Simon Flexner, Director of the Rockefeller Institute for Medical Research and a Trustee of the Rockefeller Foundation, and like him stressed rigorously experimental medical research.

Alan Gregg, who was one of the early staff members of the DME and who took over the directorship of the Division on Pearce’s death in 1930, said that the Division was created when it was realized that progress in public health depended on the “growth, activity and effectiveness” of medical education in the countries where the Foundation was operating.

Unlike the IHB, DME had few staff members. For several years, Pearce conducted surveys himself with the help of an advisory council. Only in 1922 was he expected to reduce his travels and “establish headquarters in New York and organized office”. The possibility of reorganizing the Foundation and the General Education Board (GEB), which had responsibility for medical education in America, was discussed but the status quo was “favored”. René Sand was considered for carrying out surveys in Europe.

Its functions were teaching (including research) of the premedical and medical sciences, of public health and nursing, while those of the IHB related to field operations in public health, research which bore upon such operations, and the development through aid to laboratories, statistical services, etc. and by fellowships of international, central and local health facilities, organization and personnel.

Future developments concerning the Rockefeller Foundation are incorporated in the discussion of Gunn’s career with that organization.

The Red Cross Medical Conference (Cannes, 1919)

We who have been joined together in close association during this war in fighting the common enemy, an enemy of civilization, are to continue in closer bonds of friendship, because we are joined together not to forge weapons of destruction, but united to consider what we can contribute for the healing of the nations. There is assembled in Paris delegates to consider the formation of a League of Nations. (William Welch)

William Welch’s introductory words were spoken in April 1919 at Cannes, where an extraordinary collection of public health leaders of the 20^th century had gathered. Among the more than 50 specialists invited, we find, in addition to Welch, the names of Biggs, Hugh Cumming, C Golgi, A Laveran, E Marchiafava, Newsholme, Rose, Sir Ronald Ross, Emile Roux, Frederick Russell, and  Widal.

The meeting was called at the request of Henry P Davison, who was a New York banker and who in 1917 had been appointed Chairman of the War Council of the American Red Cross (ARC). He wished to create an international Red Cross capable of controlling epidemic diseases and organizing relief for those made destitute by war. He envisioned:

A medical force organized which would formally adopt a regime for fighting tuberculosis and that there would be a world-wide fight against the plague. There would also be adopted a recognized formula for treating with other plagues incident to certain localities, such as yellow fever, typhus, etc.

Davison looked to the Cannes Conference for expert scientific advice.

The US delegation sailed for Europe on March 15. During the voyage, Biggs drew up a statement of general purpose and scope of work to be undertaken by the International Red Cross (IRC). It included:

It should be the aim and duty of the IRC … to aid and contribute in every practicable way within the limits of its resources…to the betterment of the health and general welfare of the peoples of the world without reference to race, nationality, color or religious belief, particularly directing its activities at first to those peoples and in those areas where the need is most urgent, where the opportunities are greatest and the possibilities of large returns most promising, and which have suffered most severely from the ravages of war.

As the prevalence of disease, unsanitary conditions and excessive death rates are almost universally and inseparably connected with poverty and ignorance and as these conditions are interdependent, the IRC … should also initiate aid and direct measures among less forward nations looking to the promotion of education especially along vocational lines and to the improvement of economic conditions so that the productivity of the soil and the productivity of labor may be increased.

The activities of the IRC should be specially directed to cooperative efforts in control of certain of the great epidemic diseases of the world whose causation and manner of spread is known and which have an international significance in that they constitute an international menace with a view to their possible eradication or their restriction to the narrowest possible geographical limits. Reference is made to such disease as: yellow fever, typhus fever, plague, cholera, hookworm and possibly several others.

The IRC should create a bureau for the collection, analysis, publication and distribution of information on public health and sanitation including dietetics and soil pollution. It should also collect and distribute similar information in relation to the cultivation of the soil, agricultural machinery and similar topics and should arrange for and conduct demonstrations in those countries where they are most needed.

The IRC should give detailed consideration to two subjects of primary importance, viz.: child welfare, including measures for reduction of infant mortality, and tuberculosis.

The IRC would from time to time undertake measures for the control of certain infectious diseases endemic to such an extent in some countries or in some localities as to interfere profoundly with the physical, intellectual, economic and industrial development of the inhabitants – hookworm and malarial fever are notable diseases of this kind.

The IRC should establish at its headquarters a public health institute or training school for the technical instruction of persons to be employed in its various lines of work.

Biggs wrote to his wife: We have been working hard and with great results, I think… It (the first draft of our scheme) is really mine and I drew this up. It provides for a great international philanthropic organization to aid in giving health and equality of opportunity to the nations of the world. Perhaps they will discard it at Cannes as being too broad and too Utopian. He was right; the Conference failed to adopt the comprehensive strategy he had laid out. In fact, even the less ambitious ones it did agree on went far beyond what was politically acceptable or economically feasible at the time, including, as it did – the control of typhus fever to “be at once undertaken as an emergency relief measure,” the selection of child welfare work “as the first important constructive activity,” accurate and full registration of vital statistics, establishment of public health laboratory service “for every community,” the employment of public health nurses and health visitors, the control of tuberculosis, malaria and venereal diseases, “the erection of buildings to be used as health and community centers,” the provision of “proper housing for workingmen” and the training of school children “in all grades in the subjects of personal and general hygiene, and in the inculcation of proper health habits during school life,” all elements that featured in the then more progressive circles of public health in America and Europe.

The conference did lead, however, to the creation of the League of Red Cross Societies (LRCS). Although Biggs served briefly as its Medical Director in 1920 followed by Winslow in 1921, an IRC along the lines envisioned by Davison never materialized. Feuding with the rival International Committee of the Red Cross (ICRC), a Geneva-based organization that had been in existence since 1863, did not help matters. LRCS attempts to become involved in the containment of epidemics in Eastern Europe collapsed from lack of funds. Neither the American nor British governments, nor their Red Cross Societies, endorsed fund raising for the LRCS. It moved from Geneva to Paris in late 1921 where it concentrated on popular health and nursing education. However, partly due to continuing “warring”, a word used by René Sand in 1929, between “Red Cross interests”, the LRCS remained a “small organization”. Sand was a major figure in European social medicine. Gunn also felt that the LRCS was “hurt a little by American money”; it inhibited other countries from increasing their contributions.

A second initiative by public health officials from different countries was more successful. In December 1920 the League of Nations’ Council approved the creation of a health organization as part of the League.

The League of Nations Health Organization (LNHO)

Disease is the common enemy of mankind, and only through joint counsel and action can it be successfully fought. Just as the Allies needed a united command to ensure victory, so the human family needs leadership to cope with world-wide sources of disease and death. (Raymond D Fosdick, “The League of Nations is Alive”, June 1920 Atlantic Monthly)[1]

Of all the health problems confronting post-war Europe, typhus was by far the most threatening. During the war typhus had caused hundreds of thousands of deaths, mostly in Central and Eastern Europe. The wars’ end, with large number of troops moving from war zones back to their countries, created ideal conditions for the further spread of this louse-borne disease. Russia, where Lenin noted “either the louse will defeat socialism or socialism will defeat the louse,” was particularly threatened, as was Poland, where the withdrawing German troops had taken with them all their sanitary and medical supplies. Furthermore, an estimated one-third of the population of Poland was seriously undernourished.

Different foreign organizations came to the aid of Poland at the end of the war. Among these there was Herbert Hoover’s American Relief Administration (ARA), which within weeks of the war’s end was delivering food supplies to children. Then, with President Woodrow Wilson’s support, Hoover managed to send 6.5 million dollars of supplies to help control the worsening typhus epidemic. Other countries and organizations soon joined in sending relief supplies, as well as medical teams to help fight the epidemic. It was said that between 1918 and 1922 there were 4 million typhus cases in Poland and 25 to 30 million cases in Russia.

Dr Ludwik Rajchman (1881-1965) was in charge of the anti-epidemic campaign in Poland at the end of the war, having returned to Poland to set up a State Institute of Hygiene in Warsaw. Hans Zinsser wrote of Poland’s efforts, “The European world, and especially Germany, owes an inestimable debt to Poland. If typhus and cholera did not sweep across the Russian borders into Western countries during these years, it is to a large degree owing to the splendid sanitary organization by which the Poles guarded their frontiers”.

Rajchman had trained in Krakow and specialized in bacteriology at the Pasteur Institute. During the war he worked as a researcher at the Royal Institute of Public Health in London, lectured at King’s College, carried out investigations for the London Hospital, and was employed by the newly founded Medical Research Committee in editorial and research projects.

The disputes between Poland and Russia following the end of WWI further exacerbated the typhus situation, especially when armed conflict broke out between the two countries. In the month of January 1920 alone typhus was estimated to have caused 100 thousand cases and 12 thousand deaths there. Having failed to obtain more substantive support from the LRCS, Rajchman turned to the League of Nations for help. When the LRCS attempted to respond to the request to assist, the British Treasury firmly opposed noting, “the doctrine that the British government should tax the British taxpayer for the purpose of combating typhus in Poland on the grounds that it would be open to HMG to look for assistance from the Polish taxpayers (among others) for assistance in meeting the cost of an outbreak of typhus in UK should such occur appears to their Lordships a manifest absurdity”. The Treasury suggested, instead, that a loan should be offered but only if other countries, particularly the United States, were involved.

The League had not as yet decided upon its role in health, partly due to the rivalry between the OIHP and the League’s health officials, which delayed the League from having a permanent Health Organization until 1923. One reason was America vetoing incorporating the OIHP into the League.

An informal conference in London in July 1919 reached no definite conclusions on what to do concerning typhus. Another conference was convened in April 1920 with the specific mandate to address the typhus epidemic in Poland “with the view to protecting all of Europe against the spread of the terrible sickness towards the west”.

A temporary Epidemic Commission was established in May 1920 following the London conference. It was estimated that 2 million pounds sterling was needed to control typhus in Poland. Some also understood that helping Poland fight typhus was one way to contain the red menace. Winston Churchill, for example, joined the “Bolshevik contagion” with that of typhus. The Polish army winning a major counter offensive in August 1920 led to an armistice being signed two months later but funding remained slow and difficult. Only in the spring of 1921 did the first supply-carrying convoys set off for Warsaw. This proved possible when England contributed 50,000£ to the voluntary funds. France soon followed with an equivalent amount, and other countries contributed as well, but at a much lower level. The Commission never received the level of funding thought necessary for Poland alone. It did go on to help other countries, e.g. Greece and Latvia, but attempts to make it a permanent body failed and its activities ceased in 1923 when funds ran out.

In 1921 Sir Eric Drummond, Secretary-General of the League, asked Rajchman to take over the job as medical director of the League’s health organization, which had been agreed to by the League’s Council in December 1920. Rajchman, in two years of intensive efforts to combat typhus, had established his credentials as one of Europe’s leading public health specialists. In October 1920 Red Cross observers reported that “Rajchman has impressed us as being the most competent public health worker we have met in this part of Europe”. Winslow also supported his candidacy.

As medical director, Rajchman also served as the Secretary to the Health Committee, which was provisionally created in June 1921 before being replaced by a permanent body in 1924. The Health Committee was an advisory body to the League. Its members included Rajchman, who served as its secretary; the Health Council, which linked it with the OIHP; and members appointed for special activities. Since the United States was not a member of the League, it could not belong to the LNHO. It was the OIHP that always selected Hugh Cumming to sit on the Health Committee as its US member thus ensuring American presence in the work of the LNHO.

Rajchman was committed to the idea that an international health agency must provide technical assistance and “not mere relief”. Material relief needed to be “bound up together” with “epidemiological intelligence work (and) intimate and constant cooperation with health services”. Only by working with and through national health authorities could effective work be carried out. He believed that final responsibility for public health rested with national governments. No international agency could do the job for them.

Following a three hour meeting between Rajchman and Rose (during which time Rose supposedly did not say a single word) on how the Foundation could help him carry out his plans for the newly established Health Organization, Rose agreed to have the Rockefeller Foundation fund part of the work of the LNHO. This funding proved vital to the success of the LNHO as the League itself was consistently underfunded.

Rose, before his departure as Director of the IHB, had helped shape two major LNHO programs which the Foundation supported, the establishment and maintenance of a Special International Service of Epidemiological Intelligence and an International Interchange of Public Health Personnel. Both were to begin no later than January 1923; the Service was to last for a period of five years, while the Interchange was to continue for “not less than three years.”

At first epidemiological intelligence was seen as being primarily of importance for Europe.  Dr. Miyajima, Japan’s delegate to the League’s Health Committee, first pointed out the importance of epidemic diseases to the Far Eastern countries in October 1921. Undeterred by initial disinterest, Miyajima repeated his urgent petition at the next two Health Committee meetings, in May and August 1922, adding on the latter occasion the observation that LNHO action “would give a concrete proof that [the League’s] work was not limited to European affairs, as unfortunately, the peoples of the Far East seemed more and more inclined to suspect.” Thus chided, the Health Committee dispatched former Epidemic Commission member Norman White on a nine-month study mission to the Far East. When he returned at the end of July 1923 White urged the establishment of an epidemiological intelligence bureau in Singapore, which would serve as the node of an information network that could include Pretoria, Karachi, Madras, Saigon, Hong Kong, Shanghai, Tokyo, Melbourne, Wellington and Honolulu. In February 1924, the Health Committee unanimously approved White’s recommendation, and this action served as Rajchman’s signal to turn once more to the Rockefeller Foundation. In his outline of the “scope of work” for the proposed bureau, Rajchman included the following activities:

to collect and transmit at regular intervals, from all Far Eastern countries, information regarding the incidence and spread of infectious diseases, especially in ports and their hinterlands

to collect and transmit periodical reports of vital statistics, etc., in Far Eastern ports

to collect data regarding alterations, additions or amendments to sanitary laws and regulations

to transmit all the above-mentioned information, periodically to the ports and health administrations of all the Far East countries concerned and also to the Health Section of the LN, whose duty it shall be to communicate them to the OIHP and to the various health administrations

The Foundation approved a five-year allocation of $125,000 in special ear-marked funds, and on March 1, 1925 the Eastern Bureau formally commenced operation.

The “opening” of the Eastern Bureau and the lead-up maneuvering resulted, not surprisingly, in new tensions between LNHO and OIHP. In the eyes of OIHP, LNHO was now going beyond competition over the collection of epidemiological surveillance data to direct poaching on well-demarcated OIHP territory. The third bullet point above asserts LNHO’s right to be involved in “alterations, additions or amendments to sanitary laws and regulations,” that is, in the modification of the sanitary conventions so central to OIHP’s raison d’etre and sense of mission. The fourth bullet point adds insult to injury by specifying the transmission of data first to LNHO which would then pass it along secondarily to OIHP, thus clearly elevating LNHO over OIHP in the international health institutional hierarchy. Rajchman’s old antagonist George Buchanan was particularly sensitive about these points.

An anonymous article in the April 12, 1924 issue of the British Medical Journal which Rajchman thought “bears all the signs of Sir George Buchanan’s inspiration,” claimed that LNHO’s epidemiological intelligence activity “encroaches to some extent on the work of the Office International d’Hygiene Publique”. A year later, at the April 1925 meeting of the Health Committee, Buchanan was more public in his criticism. He dominated a large part of the discussion by making acerbic comments on the International Sanitary Convention and LNHO’s role in collecting epidemiological surveillance data and public health statistics. All of his comments were “clearly aimed at restraining the independent role of the LNHO, preventing all impressions of its being some ‘super-medical’ authority, and of safeguarding the relative position of the OIHP”.

The resolution of this conflict was another strange compromise in the tangled history of these two organizations: the Eastern Bureau would officially be considered a “regional office” of the OIHP while functionally and financially remaining a branch of LNHO. The OIHP justified this bizarre arrangement and tried to put the best face on it by claiming that what was negotiated for the Eastern Bureau was parallel to the de facto “regional” arrangements that had previously been worked out with the Pan American Sanitary Board and the Egyptian Quarantine Board. There was thus a structural symmetry of central “Office” and regional satellites in three strategic parts of the world, and this facilitated the rapid transmission of data from periphery to center that was essential for the efficient functioning of OIHP.

Working out these arrangements was more than a series of moves in a struggle for strategic advantage; it was also an actual advance for OIHP because it energized what many had begun to believe was an outmoded and moribund Office. It was good as well for LNHO because OIHP’s new organizational structure diminished conflict at least temporarily and thus seemed to reassure the Rockefeller Foundation that it would not be caught in the political crossfire of an unresolved inter-organizational dispute. The $125,000 Rockefeller grant, in any case, allowed LNHO’s Eastern Bureau to engage in a wide range of activities and to pioneer such new communications technologies as the cable and radio transmission of epidemiological information.

Even with the Eastern Bureau issue settled, however, the LNHO still found itself in some political difficulty. The big issue was money, and Rajchman now had to deal both with budget-related tensions in the League’s orbit and, a short while later, with their impact on his Rockefeller benefactors. Within the League, 1925 was a particularly difficult budget year. Nevertheless, the Health Committee approved Rajchman’s budget proposal, very likely because the Rockefeller Foundation was willing to provide a substantial allocation for international sanitary exchanges by increasing its’ underwrite from the usual one-third to almost one-half of the LNHO budget.

The League’s Financial Supervisory Commission, which had to vet the Health Committee’s recommendation, took a dim view, demanded drastic cuts, and insisted on “the necessity of not exceeding the budget of 1924 as they did not desire the Health Organization of the League to overgrow the other technical organizations”.  A firestorm ensued the outcome of which was that the League Assembly overruled its own Finance Commission and decided to approve the budget originally proposed for the LNHO. It was also understood that the LNHO budget would be stabilized at roughly one million Swiss francs per year. Rajchman may have been pleased by this turn of events, but the Rockefeller Foundation was not. It was embarrassed that its contribution to the LNHO had become entangled in intra-League squabbling, and it also realized that a stable annual budget meant that the League was not planning to assume – as was standard practice on Rockefeller grants – increasing financial responsibility for the LNHO programs that had been funded for specified periods of time.

Later developments concerning the LNHO are incorporated in the following Chapters.