International Public Health and the World Health Organization
By Amanda J. Perkett
A thorough account of international public health would be arduous to identify, as it is extremely complex and constantly changing. This chapter serves as a basic overview of some of the major factors influencing international health. It touches on the background of these factors, the role they play in different regions of the world and the prospects for their future in international public health. Additionally, this chapter looks at one of the most powerful organizations committed to addressing international health issues – the World Health Organization.
II. Equity and Health
The world’s resources are unequally distributed, leading to inequality in the health of people and thus equality is unlikely to be achieved. Disparities in health within and between countries reveal what health problems exist; furthermore, they indicate the varying faces of ill-health in different parts of the world, show where problems are most acute, and what population groups are most exposed to health risks. To reduce such disparities will require a more equitable distribution of health-related resources in order to bring them within reach of vulnerable groups.
A. Poverty and Health
Inequalities can be illustrated between countries of varying socioeconomic
profiles; they are often classified as developed and developing (or “third world”) countries. Developing countries are susceptible to early death, infant mortality, illness, and other poor health indicators. The main causes of these negative health outcomes include living conditions marked by poverty, poor shelter, and inadequate sanitation. On the contrary, poor working conditions, unemployment, poor diets, and excessive consumption of alcohol and tobacco, among other factors, are the main causes of morbidity and premature death in developed countries. The stark differences between the health of developed nations and those of developing nations expose the economic influence on health, summarily described as issues of affluence versus poverty. Areas of poverty have higher incidence of infectious and parasitic diseases, younger populations, and shorter life expectancy whereas areas of affluence have a greater prevalence of degenerative diseases, older populations, and longer life expectancy.
Similar inequalities also exist within countries, particularly developing countries. The differences can be attributed primarily to variation between urban and rural areas. Rural areas are more likely to have barriers to health-related resources such as access to health care, education and employment while urban areas tend to have greater access to safe water and sanitation. However, urban areas are not without their own problems as you will see later in this chapter.
B. Environment and Health
The environment and health are inextricably connected. Developed countries are
affected by problems of pollution from air, water, and noise in addition to health hazards created by industrialization, urban growth, and quality of housing to name a few. Developing countries, on the other hand, are mainly affected by inadequate sanitation—the lack of safe water, facilities for the disposal of solid wastes, control of disease vectors, food safety, and satisfactory housing.
i. Physical Environment
Several aspects of the physical environment have a significant effect on health-
altitude, climate, wind, air, soil, water and sanitation. Altitude affects both atmospheric pressure and temperature, which both play a role in health. Atmospheric pressure and the partial pressure of oxygen in inspired air decline in higher altitudes. Physiological differences are found in populations living in higher altitudes; these differences include blood composition, respiratory capacity, and other changes that optimize oxygen use. Temperature also declines in higher altitudes. Cold temperatures can directly cause incidences of conditions like frostbite and indirectly be associated with outbreaks of the common cold; this secondary effect is caused by an increased tendency to stay indoors away from the cold where people are subjected to more pathogens. Conversely, heat can lead to imbalance in electrolytes (salt) and heat exhaustion, which is caused by excessive sweating or dehydration. Humidity is another aspect of climate that has an effect on health. High levels of humidity can disrupt a body’s ability to regulate heat by decreasing the evaporative cooling effect of sweating. A combination of heat and humidity can result in heat stroke.
The air in our environment is critical to our health. Disasters created by high winds in the form of hurricanes, tornados, and typhoons increase mortality, as well as flooding that typically follows these events. Pollution is another component of the air that has a negative effect on health. Outdoor pollution caused by industries and transportation (smog) can cause respiratory and circulatory distress. Indoor pollution attributed to cigarette smoke, home products, and pesticides can cause headaches and respiratory problems. A serious pollutant, chlorofluorohydrocarbon (CFC), released from air conditioners, refrigerators and plastic production has been linked to depletion in the ozone layer. Because ozone helps protect the earth from ultraviolet radiation, an increase in skin cancer incidences is likely to result.
The composition of soil also has an affect on the health of the global population. Increased levels of sodium in the soil can lead to a higher prevalence of heart disease. Some elements found in soil affect health when they are dissolved in water and consumed by humans. While fluorine has the protective effect of increasing tooth hardness and resistance to tooth decay, higher concentrations of sodium have been linked to increased prevalence of heart disease and higher levels of iron may contribute to gastrointestinal problems. Moreover, zinc, uranium, copper and lead are believed to have harmful effects. Soil has also been linked with illnesses including tetanus, Legionnaire’s disease, Ascariasis, hookworm, and schistosomiasis.
Water is a basic requirement for survival. The unavailability of safe water sources poses a serious threat to health. Cholera, infectious hepatitis, and typhoid are among the many water-borne diseases that affect the health of the global population. Pollutants in water can also be harmful when ingested by humans. Water polluted by untreated sewage often causes diarrheal disease when used for drinking or bathing. Table 1 illustrates some of the more common water-borne diseases and their impact on health; many of these illnesses can be drastically reduced by improved water and sanitation.
Table 1. Estimated Impact of Water and Sanitation Problems
Impact on Health
1.8 million people die every year from diarrheal diseases; 88% is attributed to unsafe water, and inadequate sanitation and hygiene.
500 million people are at risk for trachoma; improving access to safe water sources and better hygiene practices can reduce trachoma morbidity by 27%
1.3 million people die of malaria each year; there are 396 episodes of malaria each year; improved water management can reduce the transmission of malaria and other vector-borne diseases
160 million people are infected with schistosomiasis; basic sanitation can reduce the disease by 77%
Intestinal Helminths (Ascariasis, Trichuriasis, Hookworm)
133 million people suffer from intestinal helminthes infections; access to safe water, and better sanitation and hygiene practices can reduce morbidity from these infections by 4-29%
Source: World Health Organization, November 2004
As of 2002, there were still 1.1 billion people (17% of the global population) living without improved water sources and 2.6 billion people (42% of the global population) living without improved sanitary conditions. Future projects to improve water and sanitation conditions for the world’s population will focus on increased availability, access, and utilization.
Water pollution caused by chemicals can also have dangerous health effects when ingested; illness can include heavy metal poisoning from mercury or cancer resulting form polychlorinated biphenols.
ii. Living Environment
Our living environment also includes the insects and animals that live among us. Vectors, such as mosquitoes, blackflies, and sandflies represent a significant health problem. Many diseases are attributed to mosquitoes—malaria, dengue syndrome, filariasis (elephantiasis), viral encephalitis and yellow fever. Blackflies, sandflies, and other insects are also responsible for the spread of diseases, including onchocerciasis (river blindness) and leishmaniasis (which causes sores and ulcers). A large concern regarding these vectors is their ability to carry diseases into new areas leading to outbreaks of these diseases.
Animals can spread disease and illness directly and indirectly. For example, rabies can be transmitted directly from bites from infected animals. On the other hand, animals like rodents, birds, and monkeys can be carriers of illness or disease that can be indirectly spread from the animals to humans. Animals used for food can also transmit disease or illness; chickens and ducks, along with their eggs, have been linked to salmonella. Tapeworms and trichnella worms are also associated with infected food animals.
C. Culture and Health
Sociocultural factors - including cultural practices that are detrimental to health
and/or resistant to health care and health promotion, as well as lifestyles and patterns of consumption - have effects on health. These factors include health-related beliefs about food, pregnancy, childbirth, diseases, and sanitation practices. Individual behavior also has a direct impact on health. The links between ill-health and individual behavior are more closely related in developed countries where many health risks arise from excessive consumption of food, alcohol, tobacco, and drugs. Though health risks in developed countries are not limited to indulgent behaviors; other lifestyle choices involving work and family also play a role. It has been suggested that chronic or prolonged exposure to stress can lead to hypertension, coronary heart disease, and other impediments to health.
Developing countries also face health risks associated with cultural practices or norms. Due to varying beliefs about certain foods, such as eggs, fish, and fruits, some cultures withhold them from children which can cause more harm than good (such as malnutrition). For example, in countries where papaya and other fruits are thought to cause worms in children, there is a tendency for children to suffer from avitaminosis A (vitamin deficiency), which can result in xerophthalmia (abnormal dryness of the conjunctiva and cornea of the eye) or blindness.
Culture also influences the way populations view illness, disease and their causes. The concept of body balances includes a balance between “hot” and “cold,” but does not always refer to temperature; it is believed illness is the result of an imbalance between these two opposites (referred to in the Chinese medical tradition as “yin” and “yang”). Other body balance beliefs encompass theories around energy, blood, and dislocation of body parts. For example, some populations view menstrual blood as dangerous and take precautions to avoid contamination. Cultures also attribute illness to emotions (grief, envy), weather (changing seasons, unusual variations within seasons), supernatural forces (bewitching, evil eyes, Demons), food, sexual behavior, and/or heredity.
D. Urbanization and Health
There has been a shift of populations from rural regions to urban areas, where
individuals anticipate better jobs, education, social services and other new opportunities. However, the shift to urban development and settlement is not without its own health consequences. Although urban areas are more likely to have safer water sources and better sanitation, many of the inhabitants will be living in overcrowded and highly contaminated areas like slums and shanty towns stricken with poverty. They will be exposed to noise, traffic, and air pollution. Furthermore, the effects of urbanization significantly contribute to greenhouse gas emissions, ozone depletion, land degradation, and coastal zone destruction.
E. International Cooperation through Health Systems
Health systems are by virtue social services in that society acknowledges these services and accepts responsibility for the existence, functioning, and availability of such services. In short, such services cater to the needs of the ill, strive to instill preventive measures, and extend further to create and uphold ambitions concerning the maintenance and promotion of health. Such services can furthermore be defined as “purposive processes in which health care personnel and other resources are organized and financed with varying degrees of formality.”
is well-known that epidemics cross national borders. As a result, the spread of
diseases has become an international problem requiring cooperation from States
to address it. Some
early health systems created to address these concerns include the Pan American
Sanitary Bureau, the International Office of Public Health, and the International
Health Commission; later followed the establishment of the Health Organization
of the League of Nations and the
Pan American Sanitary Bureau was the first true multilateral health agency,
established in 1902 by the First International Sanitary Conference of American
the threat of epidemics such as the plague, yellow fever and cholera, a number
of sanitary conferences were also being held in
next important health system for combating the problems of disease in a global
setting was the creation of the Health Organization of the
III. The World Health Organization (WHO): the Role, Regulation and Respect
of WHO in Public Health
A. History of the WHO
At the end of World War II, it became apparent a new health system was needed
to continue the mission of the
League, and thus the World Health Organization was created by the United
Constitution was adopted by the representatives of 61 states on
B. Objective and Functions
The objective of WHO is the attainment by all peoples of the highest possible level of health. The WHO Constitution defines health as “complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” In order to achieve this objective, the World Health Organization has been designed to perform the following functions:
(a) to act as the directing and coordinating authority on international health work; (b) to establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health administrations, professional groups and such other organizations as may be deemed appropriate;
(c) to assist Governments, upon request, in strengthening health services;
(d) to furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments;
(e) to provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups, such as the peoples of trust territories;
(f) to establish and maintain such administrative and technical services as may be required, including epidemiological and statistical services;
(g) to stimulate and advance work to eradicate epidemic, endemic and other diseases;
(h) to promote, in cooperation with other specialized agencies where necessary, the prevention of accidental injuries;
(i) to promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene;
(j) to promote co-operation among scientific and professional groups which contribute to the advancement of health;
(k) to propose conventions, agreements and regulations, and make recommendations with respect to international health matters and to perform such duties as may be assigned thereby to the Organization and are consistent with its objective;
(l) to promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment;
(m) to foster activities in the field of mental health, especially those affecting the harmony of human relations;
(n) to promote and conduct research in the field of health;
(o) to promote improved standards of teaching and training in the health, medical and related professions;
(p) to study and report on, in co-operation with other specialized agencies where necessary, administrative and social techniques affecting public health and medical care from preventive and curative points of view, including hospital services and social security;
(q) to provide information, counsel and assistance in the field of health;
(r) to assist in developing an informed public opinion among all peoples on matters of health;
(s) to establish and revise as necessary international nomenclatures of diseases, of causes of death and of public health practices;
(t) to standardize diagnostic procedures as necessary;
(u) to develop, establish and promote international standards with respect to food, biological, pharmaceutical and similar products;
(v) generally to take all necessary action to attain the objective of the Organization.
C. Organizational Structure of WHO
The Organization consists of three main organs: (1) the Health Assembly, (2) the
Executive Board, and (3) the Secretariat.
i. The World Health Assembly
The World Health Assembly is the supreme decision-making body of WHO.
It meets in May each year in
ii. The Executive Board
The primary functions of the Board are (1) to give effect to the decisions and
policies of the Health Assembly, (2) to advise it, and (3) to facilitate its work. It is composed of 32 members, technically qualified in the field of health, who are elected by the Health Assembly to three-year terms. The Board meets in January to set the agenda for the upcoming Health Assembly. During this meeting, the Board also adopts resolutions that will be forwarded to the Health Assembly. In May, the Board meets again following the Health Assembly to address administrative matters.
iii. The Secretariat
This organ of WHO, headed by the Director-General, is staffed by
approximately 3,500 health and other experts and support staff. They work on fixed-term appointments at WHO headquarters, in the six regional offices and in various countries. The Director-General is the chief technical and administrative officer of WHO and is responsible for preparing and submitting financial statements and budget estimates to the Board.
D. Membership & Governance
WHO is the largest public health agency in the world, with 192 member States. Any country who is a member of the United Nations may become a member of the Organization by accepting the Constitution. Non-UN member countries may also be admitted as members by a simple majority vote of the Health Assembly to approve their application. Furthermore, territories not responsible for the conduct of their international relations may be admitted as Associate Members upon application; these applications must be submitted on their behalf by the Member or other authority responsible for their international relations. All member states are grouped into six regions, each with its own Regional Office (see Table 2).
Table 2. World Health Organization – Six Regional
Offices and their
Regional Office for
Algeria, Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, Swaziland, Togo, Uganda, United Republic of Tanzania, Zambia, and Zimbabwe
Regional Office for the
Antigua and Barbuda, Argentina, Bahamas, Barbados, Belize, Bolivia, Brazil, Canada, Chile, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, El Salvador, Grenada, Guatemala, Guyana, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Panama, Paraguay, Peru, St. Kitts and Nevis, St. Lucia, St. Vincent and the Grenadines, Suriname, Trinidad and Tobago, United States of America, Uruguay, and Venezuela
Regional Office for
Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste
Regional Office for
Albania, Andorra, Armenia, Austria, Azerbaijan, Belarus, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, San Marino, Serbia and Montenegro, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tajikistan, The former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine, United Kingdom, Uzbekistan
Regional Office for the
Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, Somalia, Sudan, Syrian Arab Republic, Tunisia, United Arab Emirates, Yemen
Regional Office for the Western Pacific
located in the
Australia, Brunei Darussalam, Cambodia, China, Cook Islands, Fiji, Japan, Kiribati, Lao People’s Democratic Republic, Malaysia, Marshall Islands, Micronesia, Mongolia, Nauru, New Zealand, Niue, Palau, Papua new Guinea, Philippines, Republic of Korea, Samoa, Singapore, Solomon Islands, Tonga, Tuvalu, Vanuatu, Vietnam
Source: World Health Organization, 2005
The Health Assembly, the Executive Board and the Secretariat operate under the
provisions of the WHO Constitution. Additionally, all member states of the Organization are bound to abide by its principles. The Constitution drafted under the auspices of the Charter of the United Nations, assigns responsibility for the provision of adequate health and social measures to member states. The WHO defines health as “complete physical, mental and social well-being.” Within the Constitution, health is considered a fundamental right of every human being.
The Constitution is divided into 19 categorical chapters. The first chapter, containing only Article 1, states the objective of the WHO is the “attainment by all peoples of the highest possible level of health.” Chapter II, Article 2, lists the various functions of the WHO employed to achieve its objective. Some of the functions include acting as authority on international health work, assisting governments in building health services, working to eliminate epidemic, endemic and other diseases, and promoting and conducting research in the field of health. Articles 3 through 8 making up Chapter III pertain to membership and associate membership of the WHO. Membership is open to all states by approval from a simple majority vote of the Health Assembly.
The organs of the WHO, namely the Health Assembly, the Executive Board, and the Secretariat are listed in Chapter IV, Article 9, and are defined in Chapters V, VI, and VIII, respectively. Articles 10 through 37 outline the make-up, roles, and responsibilities of the three organs of the WHO. The WHO can be further broken down into committees, when deemed necessary, by proposal from the Director-General or direction fro the Health Assembly. The creation of committees is authorized in Chapter VIII, Articles 38, 39, and 40. Additionally, the Health Assembly or the Executive Board may organize conferences to address any matters within the scope of the WHO. Chapter IX, Article 41, suggests the WHO may provide for the representation of international organizations and national organizations, governmental or non-governmental. Chapter X, Article 43, specifies the location of the WHO headquarters.
Chapter XI, containing Articles 44 through 54, pertains to the establishment of the regional organizations within the WHO. Regional organizations are desirable to meet the needs of member states on more focused and individualized level; however, there may only be one regional organization in each area. The provisions in this chapter describe the process to establish such regional bodies, their structure, functions, and responsibilities to the member states and to the WHO.
The next three chapters refer to administrative and procedural matters. As specified in Chapter XII, the budget and expenses are initially prepared by the Director-General, submitted to the Executive Board, and are then forwarded to the Health Assembly along with the Board’s recommendations. Voting procedures are outlined in Articles 59 and 60 of Chapter XIII. Each member of the WHO is entitled to one vote in the Health Assembly and most decisions require a two-thirds majority vote of attending members. Chapter XIV discusses the rules pertaining to reports submitted by member states to the WHO, which includes an annual report on any action taken and progress achieved in the improvement of each state’s population.
The legal capacity, privileges and immunities are permitted by Articles 66 through 68 of Chapter XV. The legal capacity extends to any level necessary to achieve the objective of the WHO and in performing its functions. The WHO is granted equal flexibility of privileges and immunities.
Chapter XVI guides relations with other organizations, including other inter-governmental organizations, international organizations, and governmental and non-governmental national organizations.
The final three chapters of refer to the structure and force of the Constitution. Any amendments to the Constitution must be made in accordance with Chapter XVII, Article 73. The interpretation of all provisions contained in the document must be resolved in compliance with Articles 74 through 77 found in Chapter XVIII. Any disputes should be negotiated or settled by the Health Assembly; however, if the matter is not resolved, it can be referred to the International Court of Justice for further judgment on the manner in which the Constitution should be interpreted. Lastly, the Constitution takes entry-into-force pursuant to Articles 78 through 82 of Chapter XIX and remains open for signature and acceptance to all states.
E. WHO Programs
Several major WHO programs started in the mid-70’s and have continued into the
Present; these programs include the Expanded Programme on Immunization (EPI), the Special Programme for Research and Training in Tropical Diseases, and the Essential Drugs program. All existing programs are subject to evaluation, revision, and reorganization and new programs are frequently being implemented. Programs are designed to address issues of service delivery, coverage, access, management information systems, logistics, and disease surveillance with an emphasis on countries and people in greatest need.
F. Publication and Research
In addition to their extensive number of programs, WHO also conducts a
considerable amount of research and data analysis. Publications range from weekly epidemiological reports to journals to drug information databases to an annual World Health Report. WHO also maintains an online library of all of there past and current publications (WHOLIS). Additional research tools include a guide to statistical data (WHOSIS), classifications of diseases, geographical information tools, and media archives.
G. The Future of International Public Health
Historically, public health primarily addressed issues of housing, sanitation, water supply, and communicable diseases; however, there is now a focus on additional areas including the environment, economic security, domestic problems, childcare, and health education. Moreover, in the last couple of decades, there has been a shift toward strengthening primary care; as a result, the number of WHO programs devoted to primary care has increased dramatically.
At present, the World Health Organization has been revising the International Health Regulations, which will be submitted to the World Health Assembly in May for approval. The Regulations are a set of standards established to ensure security against the international spread of diseases with minimum disruption of world traffic. The revisions are being conducted in response to the changing nature of public health risks—increases in international traffic and trade, introduction of new microbes and re-emergence of old diseases.
also devotes a tremendous amount of its resources toward disease outbreaks and
emergencies, such as the recent Cholera outbreak in
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