Neutrality and Sovereignty

In a certain way, the organization’s “one China” absolutism (though sometimes fatal) might be less objectionable if the WHO did not go out of its way to engage in sovereignty disputes elsewhere around the world.

Border controversies, on the face of it, do not seem like an obvious preoccupation for a global health body. Indeed, other international health and medical organizations, most notably the International Red Cross, typically attempt to avoid becoming entangled in political disputes, and to provide treatment and aid without taking sides. “In order to continue to enjoy the confidence of all,” says the official Red Cross policy, “the Movement may not take sides in hostilities or engage at any time in controversies of a political, racial, religious or ideological nature.” Red Cross officials therefore cooperate impartially with de facto authorities in order to meet a population’s medical needs. The traditional view, as Red Cross leader Hans Haug wrote in his Humanity for All: The International Red Cross and Red Crescent Movement, is that the movement “has not been created and is not called upon to have an influence on the establishment of the system of law and society and to participate in the struggle for power within States and in the world of States.” The Red Cross’s refusal to allow the Israeli ambulance service Magen David Adom to join the worldwide network belies these claims of neutrality to an extent, but there is no question that in times of crisis an international health organization is helped enormously by a willingness to work with local authorities, whoever they are.

But the WHO’s view of public health is somewhat more expansive. “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” reads the organization’s constitution. High standards of health can be achieved, as the WHO’s “World Health for All by 2000” statement put it, “through influencing lifestyles and controlling the physical and psychosocial environment,” implicating nothing less than a “fundamental reorganization of human relationships in the world through the search for a New International Economic Order.”

Indeed, the World Health Organization’s claim to be unable to assist Taiwan out of respect for national sovereignty is all the more bizarre considering that the organization’s public documents call for political reorganization in the interest of public health. The World Health Assembly, for example, has concluded that “Israeli occupation is a serious health problem” to be remedied only by a sovereign Palestinian state. Even as it rejected Taiwanese appeals merely to participate in global health efforts, the World Health Assembly (WHA) showed no hesitation in “reaffirming the inalienable, permanent and unqualified right of the Palestinian people to self-determination, including their right to establish their sovereign and independent Palestinian State, and looking forward to the early fulfillment of this right.”

The WHO’s annual condemnations of Israel at the World Health Assembly constitute the only country-specific resolutions adopted by that body. Yet, despite the organization’s singular animosity towards Israel (“the occupying power,” as WHO reports refer to the country), Palestinian health has improved appreciably under the Israeli healthcare system. As historian Efraim Karsh has written, “mortality rates in the West Bank and Gaza fell by more than two-thirds between 1970 and 1990.” In 1967, while under Jordanian and Egyptian rule, life expectancy in the Palestinian territories was 48 years. By 2000, the figure had climbed to 72 years—higher than the average life expectancy of 68 years in the larger region of the Middle East and North Africa. The introduction of Israeli medical care similarly reduced the infant mortality rate from 60 per 1,000 live births in 1968 to 15 in 2000—a substantially lower rate than those found in Jordan and Egypt, the previous administrators of the West Bank and Gaza (at 23 and 40 per 1,000, respectively). Other measures of the Palestinian “psychosocial environment,” such as access to electricity, running water, and education, improved even more markedly over the same period.

Instead of health-related concerns in the territories, WHA resolutions and WHO “Health Situation Reports” condemn the Jewish state for requiring security checkpoints, building settlements, and responding militarily to terrorist attacks. All these may well be worthy of criticism and debate within a deliberative political body, but by presenting them as health concerns, the WHO attempts to pass off its political preferences as scientific expertise.

Politics and Science

The World Health Organization regularly holds itself up as a source of scientific rigor in public policy debates. “Although we accept that politics is part of our existence,” the WHO staff associations representative told the organization’s executive board last year, “we should not allow politics to rule us and dictate the activities of the Organization.” Public health professionals at the WHO aim at getting health outcomes to conform to some standard that is presumed to be objective and scientific. The entire discipline of public health, according to the WHO’s World Health Report 1998, is “the art of applying science in the context of politics so as to reduce inequalities in health while ensuring the best health for the greatest number.” Of course, even that statement betrays clear political judgment; for it is by no means scientifically obvious that egalitarianism should have so central a place in international public health policy.

The effect of this overriding focus on equality is evident in some prominent WHO studies. The organization’s World Health Report 2000, for instance, reported the absurd statistic that the United States ranks thirty-seventh in national performance among the world’s 191 “health systems”—placing America well behind such celebrated centers of medicine as Colombia, Morocco, and Oman. Obviously, no sensible person takes such figures seriously. The WHO can indulge in its fantasy only because of its own ideological commitments. The criteria for the health-systems ranking, devised by something called the “WHO Global Program on Evidence for Health Policy,” were primarily measures of political egalitarianism. They included “distribution of health” and “distribution of financing”—criteria which measure inequalities, but have nothing at all to do with the absolute quality of healthcare. Another WHO standard is “fairness of financial contribution.” “Colombia,” explains the report, “achieved top rank because someone with a low income might pay the equivalent of $1 per year for healthcare, while a high-income individual pays $7.6.” Predictably, the report insists that “ultimate responsibility for the performance of a country’s health system lies with government” and dismisses market-based approaches as “the worst possible way to determine who gets which health services.” More grandly, it declares that the “careful and responsible management of the well being of the population is the very essence of good government.”

No one really believes that the WHO’s findings were based on science, though their political preferences were hidden behind an elaborate facade of statistical analysis. The truth remains that science provides no action plan for government. The fact that chocolate or cigarettes are bad for you, for example, in no way settles the question of whether those products should be legal or not. Health, despite the rhetoric of the WHO, is not the summum bonum of good government.

As SARS wracked their country last spring, Taiwanese legislators petitioned the World Health Assembly: “The World Health Organization should not become a political stage,” they wrote, “politics should remain out of healthcare.” Taiwan’s was certainly a legitimate grievance, but Taipei lawmakers were asking for the impossible. There is no way to take politics out of the question of who gets which health services, for it is a political question to begin with. Any organization that, like the WHO, claims to act in the public good must hold some substantive idea of what the public good constitutes, a task of and for political judgment and deliberation. In deciding how to distribute health resources, the WHO unavoidably acts on the basis of certain political principles. Some, such as equality, may be salutary in their proper proportion; others, such as the “one China” principle, may not make sense at all. Taiwan fell victim not to the politicization of public healthcare—a senseless expression—but to the biases of the WHO’s particular political ideology. This may seem a trivial matter of semantics, but the insight that public health is always a political enterprise is often lost on healthcare professionals, especially those working for the WHO itself. Their political prejudices hide under the banner of science; their ideologies masquerade as expertise.

In practice as in theory, the notion of “public health” is often expanded to cover nearly the entire range of human experiences. It is not difficult to see how this attitude can lead to pervasive bureaucratic control of all facets of life, especially when authority is assumed over any social factor that might affect health or well-being. In 2002, for example, the World Health Assembly resolved: “Behaviors that encourage social polarization and practices of discrimination, racism and violence and provide the social and cultural basis of several wars—often the major cause of mortality and morbidity—should be considered a public health issue and appropriate strategies and programs should be found to tackle them.” In this vision, the most contentious and important political debates should be resolved not through public deliberation, but by public-health technocrats acting through a bureaucracy.

Policies such as affirmative action, which the WHO also advocates, are medical treatments for a diseased body politic. And there is little room, of course, to question the doctor’s orders.

The World Health Organization’s fault, then, is not to bring politics into what was always a political enterprise, but rather to present its political agenda as impartial medical expertise. Such a vision neutralizes political debate before it begins, replacing politics with government by medical experts. The WHO’s presentation to the 2001 United Nations World Conference Against Racism, Racial Discrimination, Xenophobia and Related Intolerance reported that “health disparities are rooted in fundamental social structural inequalities, which are inextricably related to racism and other forms of discrimination in society.” Because “mortality and health in general rarely diverge far from economics and social relations,” the WHO insists that adequate public-health policy would include “comprehensive legislation, specifically prohibiting all forms of discrimination and providing civil and criminal penalties and remedies in all spheres of public life.” All of society, it turns out, is a sick patient; all human endeavors are symptoms. A resolution of the WHO’s Western Pacific regional office makes this idea explicit:

Public health is primarily concerned with the collective action taken by society to promote and protect the health of entire populations. This may be compared with clinical medicine, which deals primarily with problems of individuals and, therefore, may be referred to as personal health services.

Policies such as affirmative action, which the WHO also advocates, are medical treatments for a diseased body politic. And there is little room, of course, to question the doctor’s orders.