World Health and World Politics: The World Health Organization and the UN System (review)

Siddiqi has presented a balanced and well-documented review of the history of the World Health Organization (WHO). At a time when the future of the specialized agencies of the UN is being questioned, this book should help future dialogue more than the impressionistic sharing of anecdotes that dominates most discussions of reform. The role of WHO is summarized by Siddiqi’s statement: “if it were to disintegrate tomorrow, it would have to be rejuvenated the day after. Accordingly, even the WHO’s strongest critics have not called for its dismemberment” (p. 212).

Siddiqi’s historical analysis focuses on the period from 1948 to 1985, from enthusiastic post-World War I hopes for international action to the realism of recessionary post-Cold War cutbacks in international funding. In the early days of WHO, the dominance of Western countries led to complaints about political pressure for Western priorities. Eastern Bloc countries withdrew to inactive status from 1949 to 1955, and the People’s Republic of China did not replace Taiwan until the late 1970s. In spite of such gaps WHO has always held strongly to the principle of universality, claiming to include in its mandate all the people of the world. The direction of complaints about politicization changed as membership grew and developing countries gained political influence. Criticisms from donor countries, which pay most of the costs, are related to the loss of control over decisions. Siddiqi tries to balance concerns about the effectiveness of WHO as reflected in another polarization, that between the “functionalism” of technically oriented programs versus broad infrastructure development.

A third of the book is devoted to a detailed analysis of the worldwide Malaria Eradication Program from 1955 to 1969. This was the largest health program ever organized, costing about $1.5 billion, before it was declared a failure with reversion to control. In comparison, the Smallpox Eradication Program from 1967 to 1979 was considered a great success, and it cost only $313 million. Appendix D in the book gives a succinct listing of the factors favoring smallpox eradication, including basic biology, ease of recognition, and the relatively simple process of immunizing children as compared with controlling elusive and bioresilient mosquitoes and parasites. Siddiqi summarizes by saying that the main reason for the malaria program’s failure was the collapse of international political will, mostly because too much was promised based on early success in the more developed countries.

A dilemma in WHO programming has been polarization between the proponents of vertical and horizontal programs. Western experts preferred and tended to fund single intervention, top-down programs. However, the malaria eradication debacle caused a shift to Primary Health Care emphasizing the development of infrastructure, with priorities set locally.

Siddiqi finished his documentation and analysis in 1985. It would be interesting to see how he would explain the decade since then. WHO/UNICEF tried to move toward a compromise position but reverted to vertical programming in promoting. This led to the Child Survival and Development Revolution and the Expanded Programme for Immunization and Polio Eradication (EPI/Polio). There was limited building of infrastructure. The most useful contribution of the Siddiqi book would be if its sections on malaria were required reading for the people now promoting polio eradication, since they will encounter many of the same problems and will need to be especially careful to avoid any assumption that experience in the Americas can be replicated in Africa.