The World Health Organization (WHO) was created in 1948 by member states of the United Nations (UN) as a specialized agency with a broad mandate for health. The WHO is the world's leading health organization. Its policies and programs have a far-reaching impact on the status of international public health.

Defined by its constitution as "the directing and coordinating authority on international health work," WHO aims at "the attainment by all peoples of the highest possible standard of health." Its mission is to improve people's lives, to reduce the burdens of disease and poverty, and to provide access to responsive health care for all people.

RESPONSIBILITIES AND FUNCTIONS

WHO's responsibilities and functions include assisting governments in strengthening health services; establishing and maintaining administrative and technical services, such as epidemiological and statistical services; stimulating the eradication of diseases; improving nutrition, housing, sanitation, working conditions and other aspects of environmental hygiene; promoting cooperation among scientific and professional groups; proposing international conventions and agreements on health matters; conducting research; developing international standards for food, and biological and pharmaceutical products; and developing an informed public opinion among all peoples on matters of health.

WHO operations are carried out by three distinct components: the World Health Assembly, the executive board, and the secretariat. The World Health Assembly is the supreme decision-making body, and it meets annually, with participation of ministers of health from its 191 member nations. In a real sense, the WHO is an international health cooperative that monitors the state of the world's health and takes steps to improve the health status of individual countries and of the world community.

The executive board, composed of thirty-two individuals chosen on the basis of their scientific and professional qualifications, meets between the assembly sessions. It implements the decisions and policies of the assembly.

The secretariat is headed by the director general, who is elected by the assembly upon the nomination of the board. The headquarters of the WHO is in Geneva. The director general, however, shares responsibilities with six regional directors, who are in turn chosen by member states of their respective regions. The regional offices are located in Copenhagen for Europe, Cairo for the eastern Mediterranean, New Delhi for Southeast Asia, Manila for the western Pacific, Harare for Africa, and Washington D.C. for the Americas. Their regional directors, in turn, choose the WHO representatives at the country level for their respective regions. There are 141 WHO country offices, and the total number of WHO staff, as of 2001, stands at 3,800. WHO is the only agency of the UN system with such a decentralized structure. The Pan American Health Organization (PAHO) existed before the birth of WHO and serves as WHO's regional office for the Americas.

The founding fathers of the UN purposely set aside a network of specialized agencies with their own assemblies, intending that technical cooperation among member states would be free of the political considerations of the UN itself. It has not always worked out this way, however. WHO could not escape entirely the political fights that occurred in the specialized agencies, and the assembly's deliberations have often reflected the political currents of the time.

The decentralized structure of WHO has added a political dimension that has its pluses and minuses. Many of the resources are assigned to the regional centers, which better reflect regional interests. On the other hand, the regional directors, as elected officials, can act quite independently—and occasionally they do. This has given rise to the impression that there are several WHOs.

Moreover, because the regional directors are elected, they need to give consideration to the requirements of reelection. Since the regional directors choose country representatives in their regions, the dynamics of personnel interaction in WHO's administration is quite unique in the UN system. Regional control over country offices is strong, leaving the WHO country representatives with limited authority or leeway for program implementation.

ACCOMPLISHMENTS AND CHALLENGES

The second half of the twentieth century saw remarkable gains in global health, spurred by rapid economic growth and unprecedented scientific advances. WHO has played a very pivotal role in setting health policies, as well as providing technical cooperation to its member states. Life expectancy rose from 48 years in 1955 to 69 years in1985. During the same period, the infant mortality rate fell from 148 per 1000 live births to below 59 per 1000. Population growth has been slowed dramatically in many of the most populous countries. Smallpox, the ancient scourge, has disappeared. Other successes include the control of lice-borne typhus and yaws. Polio and guinea worms are on the verge of total elimination. A number of other communicable and tropical diseases, including onchocerciasis and schistosomiasis, are in retreat. With universal salt iodization in place, the prospect of virtually eliminating iodine deficiency disorders (IDD), the major cause for brain damage among young children, is also in sight.

Absolute poverty is still spreading in many parts of the world, however. Disparities in health and wealth are growing between and within countries. More than one billion people are without the benefits of modern medical science. One out of five persons in the world has no access to safe drinking water. Infectious diseases alone account for 13 million deaths a year, most of them in the developing countries. Seventy percent of the poor are women. The chance of an expectant mother in the world's poorest country dying of childbirth is 500 times greater than her counterpart in the richest country.

Excessive consumption and pollution practices have produced profound climatic changes that impact on the environment and the health of human beings. Globalization of trade and marketing has led to a sharp increase in the use of tobacco, alcohol, and high fat foods, along with unhealthy lifestyles.

THE EARLY YEARS OF WHO

Initially, WHO devoted much of its resources to the fight against the major communicable diseases. Mass campaigns were waged against malaria, trachoma, yaws, and typhus, among others. Malaria turned out to be a more complex problem than anticipated, and early efforts at eradication had to be scaled back to the level of control. Efforts to improve maternal and child health services included the training of traditional birth attendants—an approach advocated by UNICEF, WHO's close partner in all child-health projects—to reduce infant and maternal deaths. WHO also followed up on the work done by its predecessor organizations on sanitary conventions. It adopted, in 1951, the International Sanitary Regulations, later (in 1971) renamed the International Health Regulations.

Beginning in the 1960s, WHO began an effort to extend health services to rural populations. In 1974, recognizing the underutilization of existing technologies to fight childhood diseases, WHO launched an expanded immunization program against polio, measles, diphtheria, whooping cough, tetanus, and tuberculosis.

HFA AND PHC

Widespread dissatisfaction with health services in the later 1960s and early 1970s led to an effort to find an alternative approach to standard health care, and eventually the joint WHO/UNICEF conference in Alma-Ata in 1979.

The goal of Health for All (HFA), adopted by member states at the 1977 World Health Assembly, called for the attainment by all people of the world of a level of health that will permit them to lead a socially and economically productive life. In 1978, WHO and UNICEF cosponsored the historic International Conference on Primary Health Care (PHC) in Alma-Ata, at which the international development community adopted PHC as the key to attaining the goal of Health for All by the year 2000.

PHC, as defined at the Alma-Ata conference, called for a revolutionary redefinition of health care. Instead of the traditional "from-the-top-down" approach to medical service, it embraced the principles of social justice, equity, self-reliance, appropriate technology, decentralization, community involvement, intersectoral collaboration, and affordable cost. The Alma-Ata Declaration on PHC envisaged a minimum package of eight elements:(1) education concerning prevailing health problems and the methods of preventing and controlling them; (2) promotion of food supply and proper nutrition; (3) an adequate supply of safe water and basic sanitation; (4) maternal and child health, including family planning; (5) immunization against the major infectious diseases; (6) prevention and control of locally endemic diseases; (7) appropriate treatment of common diseases and injuries; and (8) provision of essential drugs. Where appropriate, the employment of lay health workers from the community should be trained to tackle specific tasks, including education, and to provide first-level care, with appropriate referrals to secondary and tertiary health facilities.

Though few, if any, countries have successfully followed all the precepts of PHC as enunciated at Alma-Ata, PHC has since provided the philosophical linchpin for virtually all subsequent international health activities. In the 1960s and early 1970s, community health workers and traditional birth attendants were grudgingly accepted by many, though only as second-class health care providers, and they were scorned by others, especially by some traditionally trained allopathic medical practitioners. With Alma-Ata, however, plus the exemplary success of the work of "barefoot doctors" in China, PHC precepts and programs became respectable.

ERADICATION OF SMALLPOX

After an exhaustive and intensive effort, the last cases of smallpox were identified and treated in East Africa. In 1979 a global commission certified the worldwide eradication of this ancient scourge. The cost over the decade-long campaign came to $300 million, a small price to pay for the elimination of the disease, for which the annual cost of vaccination worldwide was close to $1 billion. No ordinary victory, this was humankind's first conquest of a deadly malady, and a clear demonstration that investment in health begets economic benefit as well as humanitarian relief.

GLOBAL STRATEGY FOR HFA

In 1979 the World Health Assembly adopted the Global Strategy for HFA, which was subsequently endorsed by the UN General Assembly. The UN resolution was the health community's attempt to mobilize the world community at large to take collaborative actions to improve the status of the world's health. The main thrust of the strategy was the development of a health-system infrastructure, starting with PHC, for the delivery of countrywide programs that would reach the entire population. The strategy called for the application of the principles of the Alma-Ata Declaration and the development of the minimum package of the eight PHC elements.

HFA was conceived as a process leading to progressive improvement in the health of people and not as a single finite target, though some indicators were recommended. It aims at social justice, with health resources evenly distributed and essential health service accessible to everyone, with full community involvement.

While member states all voted to adopt HFA via PHC, implementation lagged far behind, as economic crises loomed and political and military conflicts flared. Natural disasters also intervened. The rapid rise of the urban poor and weaknesses in the organization and management of health services resulted in waste and misuse of meager resources. Above all, poverty, its deep-rooted causes unresolved, undermined various efforts in the slow march towards HFA.

CSDR, BAMAKO, AND ARI

In the early 1980s, UNICEF launched its Child Survival and Development Revolution (CSDR) with four inexpensive interventions: growth monitoring, oral rehydration, breastfeeding, and immunization programs (commonly referred to as GOBI). After some initial reservation, and with assurances that GOBI efforts would be within the context of PHC, WHO became an active player in CSDR, which has made impressive inroads in reducing infant deaths, especially through the immunization campaign and the oral rehydration program for the control of diarrhea, which also benefited from water and sanitation programs.

WHO also joined UNICEF in launching the Bamako Initiative in the 1980s, which aimed at the provision of essential drugs and their rational use in the context of PHC, initially in African countries but later expanded to other regions. The initiative introduced the element of cost recovery as well as community management of drug supplies and sales. Indeed, in spite of the retrogressive economic situation in Africa south of the Sahara in the 1980s, infant mortality and life expectancy continued to improve gradually in Africa. These gains, however, have since been brutally reversed by the spread of HIV/AIDS.

The 1980s also saw WHO initiating a broad-scale attack against acute respiratory infections (ARI), a major cause of child mortality, and implementing the Safe Motherhood program, designed to reduce maternal deaths—which stood at 500,000 avoidable deaths, almost all in the developing countries. In these efforts, WHO was joined by UNICEF and the World Bank, which had begun to turn some of its attention to the social aspects of development. In the later 1990s, the Integrated Management of Childhood Illness program was launched to bring together a number of programs for a more rational approach.

Though there was progress, the PHC implementation was found to be limited to a number of countries and some specific areas. The principles of PHC, however, were found to be the only viable option even in the most difficult circumstances, with some adjustment of the approaches and strategies necessary in country-specific situations. The effort to introduce district-level PHC did succeed in bringing the services closer to the people who need them.

THE HIV/AIDS PANDEMIC

Although HIV/AIDS first raised its ugly head in the public eye in North America, it soon became clear that the AIDS epidemic was to become a pandemic. Under pressure from WHO, a number of governments, and various developments agencies, the pharmaceutical industry has agreed to allow the price of AIDS treatment drugs to drop from around $15,000 a year per patient in the industrialized countries to $350 in the developing countries. This will encourage more people to come forward for screening in some countries, and in other countries, with help from international organizations, programs of treatment are now a possibility. However, the principal way to fight AIDS is still prevention through education and behavioral change, as work towards an effective vaccine is making very slow progress. While no part of the world is free of the AIDS threat, AIDS spread fast and wide in Africa, especially in countries south of the Sahara. In Asia, where the population pools are much greater, the number of HIV/AIDS cases is expected to exceed that of Africa by 2005.

In fighting AIDS, development agencies of the UN system have joined together to form UNAIDS, in which WHO plays the lead technical role. The pandemic is now such a serious threat to entire societies that it has been brought to the UN Security Council as a matter of grave security concern.

YEAR 2000 GOALS

In 1990, WHO joined with UNICEF in urging the UN Summit for Children to set Year 2000 goals. These goals included increased immunization rates; reduction of infant, under five, and maternal mortality rates; water and sanitation, as well as education for all; the reduction of malnutrition; and the elimination of micronutrient disorders.

After the end of the Cold War, the hope for a "peace dividend" from disarmament did not materialize. On the contrary, with a few exceptions, since that time the volume of development funds from the industrialized countries has shrunk. The 2001 session of the UN General Assembly is likely to be disappointing in its review of the summit goals. The water, sanitation, and education for all goals will certainly fall far short of target. There is still hope, however, for the elimination of polio and guinea worms, as well as the virtual elimination of iodine deficiency disorders.

HEALTH PROMOTION AND OTHER ACTIVITIES

In 1982 WHO undertook a reorientation of health education, designed to expand its community approach and include communication theories and practice. In 1987 the term "health education" was changed to "health promotion" to denote a broader, ecological approach to the work of facilitating "informed choices" by people on health matters.

The first international consultation on this subject was held in Ottawa in 1986, followed by consultations in Adelaide in 1988, Sundsvall in 1991, and Jakarta in 1997. WHO's new approach calls for broader societal involvement, and in the eastern Mediterranean region, member nations adopted social mobilization as the strategy for health promotion. Individual programs, such as the tuberculosis and micronutrient elimination programs, adopted similar stances.

WHO publishes a number of technical journals, the most important of which is the WHO Bulletin, and maintains a media and public relations unit. Every year, World Health Day is observed on April 7, the day, in 1948, when WHO came into being. Each World Health Day is devoted to a particular theme, and material is made available for member states to commemorate the day with a program focus.

Noteworthy, but less publicized, activities of WHO include its worldwide efforts in mental health, oral health, food safety (including the FAO/WHO Codex Alimentarius Commission), health in the work place, elder care, chemical safety, veterinary health, cancer, cardiovascular diseases, and health and the environment. Its essential drug program has had a major impact on the rational use of medicines in developing countries.

WHO maintains a network of collaborating centers, which engage in work in various specific fields. It also maintains a working relationship with a large number of nongovernmental organizations involved in health and development. These organizations are accredited and approved by the World Health Assembly.

YEAR 2020 GOALS

The World Health Assembly has adopted the following set of new goals to be reached by, or before, 2020:

• By 2005, health equity indices will be used within and between countries as a basis for promoting and monitoring equity in health.
• By 2010, transmission of Chagas' disease will be interrupted, and leprosy will be eliminated.
• By 2020, maternal mortality rates will be halved; the worldwide burden of disease will be substantially decreased by reversing the current trends of incidence and disability caused by tuberculosis, malaria, HIV/AIDS, tobacco-related diseases, and violence; measles will be eradicated; and lymphatic filariasis eliminated.
• By 2020, all countries will have made major progress in making available safe drinking water, adequate sanitation, food and shelter in sufficient quantity and
• quality; all countries will have introduced and be actively managing monitoring strategies that strengthen health-enhancing lifestyles and weaken health-damaging ones, through a combination of regulatory, economic, educational, organization-based, and community-based programs.
• By 2005, member states will have operational mechanisms for developing, implementing, and monitoring policies that are consistent with the HFA policy.
• By 2010, appropriate global and national health information, surveillance, and alert systems will be operational; research policies and institutional mechanisms will be operational at global, regional, and country levels; and all people will have access throughout their lives to comprehensive, essential, quality health care, supported by essential public health functions.

WHO has also launched a series of initiatives, including programs to roll back malaria, stop the spread of tuberculosis, fight the AIDS pandemic, and curtail tobacco use. A breakthrough in the drastic reduction of the cost of AIDS treatment drugs is likely to impact the AIDS fight. Negotiation for a tobacco-control convention may lead to greater success for WHO's Tobacco-Free Initiative. With additional resources from private foundations, WHO, in partnership with the World Bank and UNICEF, has launched an ambitious Global Alliance for Vaccines and Immunization (GAVI). Malnutrition, which accounts for nearly half of the 10.5 million deaths each year among preschool children, will continue to be a priority item in the years to come.

WHO has also undergone a number of reorganizations, the latest resulting in nine clusters, each covering a number of programs.

In addition to the two clusters on management and governing bodies, the program clusters are: communicable diseases, noncommunicable diseases, sustainable development and health environments, family and community health, evidence and information for policy, health technology and pharmaceuticals, and social change and mental health.

DIRECTORS GENERAL

There have been a total of five directors general. Dr. Brock Chisholm, a psychiatrist from Canada, was the first. He was succeeded by Dr. Marcolino Candau of Brazil, who ran the organization for twenty years. Dr. Halfdan Mahler, a tuberculosis specialist from Denmark, took the helm after Candau. Mahler oriented the organization towards development, launched the PHC movement, and confronted the infant formula and pharmaceutical industries on health grounds. After fifteen years, he was succeeded by Dr. Hiroshi Nakajima of Japan, who ran the organization for ten years. The current director general is Dr. Gro Harlem Brundtland, a physician from Norway and a former prime minister of that country. Brundtland has placed considerable emphasis on advocacy at the political level.

JACK CHIEH-SHENG LING

(SEE ALSO: Alma-Ata Declaration; Barefoot Doctors; Blood-Borne Diseases; Communicable Disease Control; Famine; Global Burden of Disease; Health Promotion and Education; HIV/AIDS; Immunizations; Infant Mortality Rate; International Health; Iodine; Maternal and Child Health; Poverty; Sanitation in Developing Countries; Smallpox; Thyroid Disorders; Tropical Infectious Diseases; UNICEF; Waterborne Diseases; World Bank)