Nitsan Chorev. The World Health Organization between North and South. Ithaca: Cornell University Press, 2012. 288 pp. $45.00 (cloth), ISBN 978-0-8014-5065-5.
Reviewed by Joanna Radin (Yale University)
Published on H-Diplo (October, 2012)
Commissioned by Seth Offenbach
The “How” of the WHO
In the aftermath of World War II a range of international organizations emerged to manage problems that transcended national borders. One such agency was the World Health Organization (WHO), established in 1948 with headquarters in Geneva, Switzerland. Over the last sixty-five years, the WHO has played a prominent and often contentious role in shaping the landscape of international health.
Students of international organizations, health diplomacy, and public health alike have been chagrined by the realization that there are precious few in-depth studies of the WHO, its policies, practices, and history. As a historian of science and medicine with strong interests in the emergence of “global health,” I am always seeking new work, which necessarily requires looking to disciplines adjacent to my own. Sociologist Nitsan Chorev’s The World Health Organization between North and South is a welcome contribution towards filling this conspicuous gap.
The primary contribution of Chorev’s book is its focus on the strategic practices deployed by WHO leadership in efforts to negotiate between the needs and demands of nations of the global North and those of the global South. This is the “North” and “South” of the title, which in her study are understood as proxies for poor/developing and wealthier/developed nations. Chorev’s attention to strategy is the “how” of the WHO referred to in the title of this review.
The crux of her argument is that an international organization, particularly one that is created to serve a diverse array of interested actors, has the challenge of responding to the needs and demands of those actors while also maintaining a loyalty to its own foundational values. This is meant to be a story of how organizations survive amidst shifting challenges served up by what Chorev refers to as the “exogenous” environment, by which she is largely concerned with global economic circumstances. Extrapolating from the case of the WHO, she argues that “International bureaucracies have the capacity to restructure the global ideational regimes that member states impose upon them, and ... they restructure these regimes to fit their own institutional cultures” (p. 2). Her substantive intervention is to identify the adaptive strategies that international bureaucracies like the WHO employ in their efforts to remain relevant.
The first two chapters lay the conceptual groundwork for her argument. Chapter 1 offers an explanation for the lack of attention to the WHO and other kinds of international organizations on behalf of organizational and political sociologists who study international relations. She suggests that a state-centered focus has long dominated, leading international bureaucracies like the WHO to be taken for granted as passive and neutral arenas in which events play out. Her effort to reinterpret the WHO as an agent of “strategic adaptation” is a perceptive and important move towards complicating this view. In her account, the WHO emerges as both an arena and an interested actor, with resources for creatively responding to forces that undermine or threaten its core commitments to health. Chorev demonstrates the dynamic and dialectical interplay between the WHO and those agents which have challenged its authority, including member states as well as multinational corporations and other international institutions, such as the World Bank.
In chapter 2 Chorev presents a more fine-grained description of strategic adaptation as well as the forces that limit and therefore structure the kinds of strategies available to international organizations. These constraints include the dependence of such organizations on external funds provided by member states with variable degrees of power and influence; on procedural factors like voting arrangements and perhaps more significantly the structural dependence of “poor” countries on “rich” ones; and finally, what she calls “normative” dependence. This last factor refers to the need for international organizations to maintain their reputations as internally legitimate and managerially competent and demonstrates the diplomatic factors that constrain--but do not eviscerate--the agency of such institutions. In seeking to influence policies and practices, international bureaucracies like the WHO must neither exceed their original mandate nor violate tacit commitments to neutrality. This, however, does not mean they are not deeply invested in promoting particular agendas.
Chorev explains that it is precisely because such constraints have been so well documented in existing studies of international organizations that it is assumed that such institutions have no latitude in influencing policy outcomes, particularly in circumstances when their interests or mandate clash with external expectations. The contribution of this book to the literature on international organizations is that it is “working against neorealist accounts of organizations as arenas for acting out power relationships that don’t grant them their own causal power” (p. 18) and, as such, is engaged in an effort to identify the specific factors that enable international organizations to advance or at least protect their own interests under conditions of external pressures. This is what leads her to choose two moments of conflict, where the stakes are high and the strategies of the WHO can be seen more clearly.
The substantive core of the book offers an interpretation, in these terms, of two times of transition in the organization’s history. The first focuses on the WHO’s efforts to respond to developing countries’ call for a New International Economic Order (NIEO) during the 1970s and 1980s. During this period the WHO was faced with supporting health programs that could address the needs of nations of the global South. The second focal period comes after an era of debt crisis, structural adjustment, the increasing quantification of health through the rise of the World Bank, the introduction of the Disability-Adjusted Life Year (DALY), and weak WHO leadership in the 1980s (discussed in chapter 5). Here, Chorev looks at how the WHO managed its commitments during the rise of neoliberalism during the late 1990s and 2000s.
During the first period, in a mid-1970s episode described in chapter 3, WHO Director-General Halfdan Mahler championed an approach known as “Health for All by 2000.” This campaign drew its authority from the WHO’s original mandate, defined in the institution’s constitution as “the attainment of health by all peoples.” Mahler’s proposal resurrected this core commitment and strategically augmented it by making it subject to a deadline. The aim was to move away from the biomedical focus that had dominated the twenty-year leadership of his predecessor, malariologist Marcolino Candau. Mahler sought to address the demands of the NIEO by returning to the social focus, concerned with improvement of health infrastructure through investments in primary health care (PHC). Such an approach was more in line with the commitments of the WHO’s founding director, psychiatrist Brock Chisholm.
Chorev points out that while the NIEO was oriented towards economic development, WHO leadership inverted those assumptions, making the economic growth dependent upon social development, with health as a central component. The pinnacle of this effort was the 1978 Alma-Ata International Conference on Primary Health Care, held in the Soviet Union. Not only did this summit appear to signal a new commitment to the social determinants of health, it was a remarkable diplomatic coup during an era of intense cold war.
However, Mahler’s strategic inversion of the assumed relationship between economic and social development was soon undermined by an economically driven retaliatory effort. The Rockefeller Foundation, a philanthropic organization with a public health history deeper than that of the WHO, partnered with the World Bank. Together, they co-opted and augmented the language of primary health care by promoting an agenda of “selective primary health care” (p. 81). The addition of the word “selective” undermined the holistic, social focus of Mahler’s vision of primary health, which encompassed everything from animal husbandry to education. Instead, selective primary health care prioritized four highly specific interventions: immunization, oral rehydration, breastfeeding, and anti-malarials (GOBI). Later, this discrete set of priorities was augmented by the addition of female literacy, family planning, and food supplementation (FFF).
In Chorev’s interpretation of this episode, already well known to global health scholars, “Health For All” represented the WHO’s effort to adapt to the exogenous environment by “distorting” the focus of its compliance with the NIEO. Yet, this strategic adaptation provoked a second-order strategic adaptation on behalf of wealthy member states and other external forces. This, she argues, dramatically undercut the aspirations of the WHO and facilitated the encroachment of economic logic into matters of emerging regimes of global governance.
With the 1998 appointment of Gro Harlem Brundtland, former prime minister of Norway, the WHO attempted to reckon with the consequences of Ronald Reagan-Margaret Thatcher-era neoliberalism. Chorev argues that, whereas the agency had resisted economic logic in the 1970s under Mahler, Brundtland opted to recast the priorities of the WHO in economic terms. She did this by emphasizing the importance of health for economic growth, rather than as a fundamental part of a nation’s social development. In a controversial move, described in chapter 6, Brundtland--whose political reputation had been built on her elevation of environmental issues to matters of global concern through an emphasis on ideas of sustainability--recruited economists to bolster this position.
Chorev observes that media savvy of economists like Jeffrey Sachs facilitated Brundtland’s strategy to “co-opt economists by giving them the task of presenting WHO’s position” not to health ministers, who were already invested in the importance of health, but to heads of state and to the public (p. 169). Rather than viewing neoliberal ideology and the World Bank as a threat, Brundtland chose--or perhaps was compelled--to comply in strategic terms that effectively “turned the World Bank’s reasoning on its head” (p. 171). Brundtland’s strategy resulted in a transformation of the WHO that aligned it more closely with the dominant economic logic. As Chorev argues, such a transformation was accomplished in order to defend the organization’s core preferences and values, but it also reflected a definite constriction of the WHO’s capacity for strategic adaptation since the time of Mahler. It was through a multipronged effort to rebrand the WHO that it thus re-integrated itself into the dominant framework governing global affairs; at what cost remains to be fully seen.
In both time periods, the 1970s-80s and 1990s-2000s, strategic adaptation was performed through dedicated efforts to alter the very meanings of the various demands facing the institution. Chorev concludes that, as a result, the nature of the compliance that the WHO has achieved is one that very often “distorted” the original demands made upon the organization. The word “distort” is Chorev’s term and its valence is not always self-evident; she refrains from casting judgment, choosing instead to explain that “distortion” is a strategy that international bureaucracies prefer to outright disagreement in that it minimizes the risk of being punished--for example by having states withdraw membership, refuse to pay dues, or publicly condemn the organization.
In this light, the endurance of the WHO has been a product not only of compromise but also of repeated reframing of the terms upon which compromise and consensus can be reached. Has strategic adaptation served the WHO well or is this an account of an organization being repeatedly bested at its own game? The evolutionary undertones of Chorev’s description of strategic adaptation is a tacit reminder that there may come a point where organizations like the WHO will fail to adapt. And it is not at all clear that what will emerge in their place will serve the greater good.
In tandem with her depiction of the power and perils of strategic adaptation, Chorev’s study presents a picture of leadership, particularly that of individuals like Mahler or Brundtland, that may exceed her intentions. Though she acknowledges that director-generals cannot operate with complete freedom (can anyone?), during times of weak leadership, the WHO has been less able to engage productively in strategic adaptation.
Understanding the “who” of WHO, beyond the highly visible role of the director-general, is also important for understanding how the organization functions. I found myself missing a robust characterization of the WHO secretariat and the workings of the diverse membership itself. In addition to its member nations, the WHO is constituted, in large part, by its staff and an ever-changing network of experts drawn from around the world.
In this sense, the WHO is an even more dynamic institution than Chorev’s analysis would have us believe. These shifting assemblages of scientists, physicians, and public health officers are the people who comprise the expert advisory committees that write technical reports commissioned by the director general. Such technical reports, which are a key set of sources for Chorev, are highly mobile distillations of the values of globally distributed experts who periodically assemble at Geneva to tackle problems large and small. The circumstances of the production of these reports, which have been published continually since 1950, provide an important way into examining how expertise is configured and circulated within and beyond the bureaucratic structure of WHO. Such reports disseminate recommendations of experts, who may be engaged in their own practices of strategic adaptation!
Furthermore, in addition to considering that strategic adaptation may happen within international organizations as well as between them, it is also worth asking who, specifically, is a participant in any of the WHO’s study groups and commissions. The answer may reveal the circumstances that have led the agency to project an image of itself as pulled between North and South. Chorev takes these dichotomies, “North” and “South” and “developing” and “developed,” at face value. Yet it seems clear that future efforts to depict the constraints on and resources available to contemporary international bureaucracies will be greatly enhanced by more rigorously engaging histories of colonialism, development, and Cold War science. Doing so can serve the important task of critically interrogating the connotations of “poor” and “rich,” potentially revealing previously obscured axes under which nations might be or become allied. The term “global health,” itself, is one that is beginning to invite historical scrutiny. Chorev’s very emphasis on strategic adaptation points to the need to include attention to the rhetorical work such dichotomies perform for organizations like the WHO as well as the scholars who seek to interpret the actions of such institutions.
Along these lines, Chorev’s book reveals many productive avenues for further research and methodological innovation. I am particularly interested to see studies about the WHO--and other such international bureaucracies--that look beyond headquarters as a place for uncovering archival materials. What kind of portrait of WHO can be gained from the vantage point of different places around the globe? Are there instances when the local efforts of WHO-affiliated scientists, physicians, and other technical experts diverged from the recommendations or strategic messages of WHO leadership? What kinds of technologies and administrative infrastructures--like standardized laboratory practices, training programs, or computing capacities--have come to function as strategic resources? Chorev concludes her book by acknowledging that whatever happens to international organizations like the WHO, “they are still a part of history” (p. 241). In that spirit, I conclude this review with a call for continued attention to the complex historical “how” of WHO.
If there is additional discussion of this review, you may access it through the network, at: https://networks.h-net.org/h-diplo.
Joanna Radin. Review of Chorev, Nitsan, The World Health Organization between North and South.
H-Diplo, H-Net Reviews.
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