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• Published: 07 April 2020

What is global health? Key concepts and clarification of misperceptions

Report of the 2019 GHRP editorial meeting

• Xinguang Chen 1 , 2 ,
• Hao Li 1 , 3 ,
• Don Eliseo Lucero-Prisno III 4 ,
• Abu S. Abdullah 5 , 6 ,
• Jiayan Huang 7 ,
• Charlotte Laurence 8 ,
• Xiaohui Liang 1 , 3 ,
• Zhenyu Ma 9 ,
• Zongfu Mao 1 , 3 ,
• Ran Ren 10 ,
• Shaolong Wu 11 ,
• Nan Wang 1 , 3 ,
• Peigang Wang 1 , 3 ,
• Tingting Wang 1 , 3 ,
• Hong Yan 3 &
• Yuliang Zou 3  

Global Health Research and Policy volume  5 , Article number:  14 ( 2020 ) Cite this article

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The call for “W orking Together to Build a Community of Shared Future for Mankind” requires us to improve people’s health across the globe, while global health development entails a satisfactory answer to a fundamental question: “What is global health?” To promote research, teaching, policymaking, and practice in global health, we summarize the main points on the definition of global health from the Editorial Board Meeting of Global Health Research and Policy, convened in July 2019 in Wuhan, China. The meeting functioned as a platform for free brainstorming, in-depth discussion, and post-meeting synthesizing. Through the meeting, we have reached a consensus that global health can be considered as a general guiding principle, an organizing framework for thinking and action, a new branch of sciences and specialized discipline in the large family of public health and medicine. The word “global” in global health can be subjective or objective, depending on the context and setting. In addition to dual-, multi-country and global, a project or a study conducted at a local area can be global if it (1) is framed with a global perspective, (2) intends to address an issue with global impact, and/or (3) seeks global solutions to an issue, such as frameworks, strategies, policies, laws, and regulations. In this regard, global health is eventually an extension of “international health” by borrowing related knowledge, theories, technologies and methodologies from public health and medicine. Although global health is a concept that will continue to evolve, our conceptualization through group effort provides, to date, a comprehensive understanding. This report helps to inform individuals in the global health community to advance global health science and practice, and recommend to take advantage of the Belt and Road Initiative proposed by China.

“Promoting Health For All” can be considered as the mission of global health for collective efforts to build “a Community of Shared Future for Mankind” first proposed by President Xi Jinping of China in 2013. The concept of global health continues to evolve along with the rapid development in global health research, education, policymaking, and practice. It has been promoted on various platforms for exchange, including conferences, workshops and academic journals. Within the Editorial Board of Global Health Research and Policy (GHRP), many members expressed their own points of view and often disagreed with each other with regard to the concept of global health. Substantial discrepancies in the definition of global health will not only affect the daily work of the Editorial Board of GHRP, but also impede the development of global health sciences.

To promote a better understanding of the term “ global health” , we convened a special session in the 2019 GHRP Editorial Board Meeting on the 7th of July at Wuhan University, China. The session started with a review of previous work on the concept of global health by researchers from different institutions across the globe, followed by free brainstorms, questions-answers and open discussion. Individual participants raised many questions and generously shared their thoughts and understanding of the term global health. The session was ended with a summary co-led by Dr. Xinguang Chen and Dr. Hao Li. Post-meeting efforts were thus organized to further synthesize the opinions and comments gathered during the meeting and post-meeting development through emails, telephone calls and in-person communications. With all these efforts together, concensus have been met on several key concepts and a number of confusions have been clarified regarding global health. In this editorial, we report the main results and conclusions.

A brief history

Our current understanding of the concept of global health is based on information in the literature in the past seven to eight decades. Global health as a scientific term first appeared in the literature in the 1940s [ 1 ]. It was subsequently used by the World Health Organization (WHO) as guidance and theoretical foundation [ 2 , 3 , 4 ]. Few scholars discussed the concept of global health until the 1990s, and the number of papers on this topic has risen rapidly in the subsequent decade [ 5 ] when global health was promoted under the Global Health Initiative - a global health plan signed by the U.S. President Barack Obama [ 6 ]. As a key part of the national strategy in economic globalization, security and international policies, global health in the United States has promoted collaborations across countries to deal with challenging medical and health issues through federal funding, development aids, capacity building, education, scientific research, policymaking and implementation.

Based on his experience working with Professor Zongfu Mao, the lead Editors-in-Chief, who established the Global Health Institute at Wuhan University in 2011 and launched the GHRP in 2016, Dr. Chen presented his own thoughts surrounding the definition of global health to the 2019 GHRP Editorial Board Meeting. Briefly, Dr. Chen defined global health with a three-dimensional perspective.

First, global health can be considered as a guiding principle, a branch of health sciences, and a specialized discipline within the broader arena of public health and medicine [ 5 ]. As many researchers posit, global health first serves as a guiding principle for people who would like to contribute to the health of all people across the globe [ 5 , 7 , 8 ].

Second, Dr. Chen’s conceptualization of global health is consistent with the opinions of many other scholars. Global health as a branch of sciences focuses primarily on the medical and health issues with global impact or can be effectively addressed through global solutions [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. Therefore, the goal of global health science is to understand global medical and health issues and develop global solutions and implications [ 7 , 9 , 15 , 17 , 18 , 19 ].

Third, according to Dr. Chen, to develop global health as a branch of science in the fields of public health and medicine, a specialized discipline must be established, including educational institutions, research entities, and academic societies. Only with such infrastructure, can the professionals and students in the global health field receive academic training, conduct global health research, exchange and disseminate research findings, and promote global health practices [ 5 , 15 , 20 , 21 , 22 , 23 ].

Developmentally and historically, we have learned and will continue to learn global health from the WHO [ 1 , 4 , 24 , 25 ]. WHO’s projects are often ambitious, involving multiple countries, or even global in scope. Through research and action projects, the WHO has established a solid knowledge base, relevant theories, models, methodologies, valuable data, and lots of experiences that can be directly used in developing global health [ 26 , 27 , 28 , 29 ]. Typical examples include WHO’s efforts for global HIV/AIDS control [ 13 , 30 , 31 , 32 ], and the Primary Healthcare Programs to promote Health For All [ 33 , 34 ].

The definition of Global Health

From published studies in the international literature and our experiences in research, training, teaching and practice, our meeting reached a consensus-global health is a newly established branch of health sciences, growing out from medicine, public health and international health, with much input from the WHO. What makes global health different from them is that (1) global health deals with only medical and health issues with global impact [ 35 , 5 , 36 , 10 , 14 , 2 ] the main task of global health is to seek for global solutions to the issues with global health impact [ 7 , 18 , 37 ]; and (3) the ultimate goal is to use the power of academic research and science to promote health for all, and to improve health equity and reduce health disparities [ 7 , 14 , 15 , 18 , 38 ]. Therefore, global health targets populations in all countries and involves all sectors beyond medical and health systems, although global health research and practice can be conducted locally [ 39 ].

As a branch of medical and health sciences, global health has three fundamental tasks: (1) to master the spatio-temporal patterns of a medical and/or health issue across the globe to gain a better understanding of the issue and to assess its global impact [ 40 , 41 , 42 , 43 ]; (2) to investigate the determinants and influential factors associated with medical and health issues that are known to have global impact [ 15 , 40 , 41 , 42 , 43 ]; and (3) to establish evidence-based global solutions, including strategies, frameworks, governances, policies, regulations and laws [ 14 , 15 , 28 , 38 , 44 , 45 , 46 , 47 ].

Like public health, medicine, and other branches of sciences, global health should have three basic functions : The first function is to generate new knowledge and theories about global health issues, influential factors, and develop global solutions. The second function is to distribute the knowledge through education, training, publication and other forms of knowledge sharing. The last function is to apply the global health knowledge, theories, and intervention strategies in practice to solve global health problems.

Understanding the word “global”

Confusion in understanding the term ‘global health’ has largely resulted from our understanding of the word “global”. There are few discrepancies when the word ‘global’ is used in other settings such as in geography. In there, the world global physically pertains to the Earth we live on, including all people and all countries in the world. However, discrepancies appear when the word “global” is combined with the word “health” to form the term “global health”. Following the word “global” literately, an institution, a research project, or an article can be considered as global only if it encompasses all people and all countries in the world. If we follow this understanding, few of the work we are doing now belong to global health; even the work by WHO are for member countries only, not for all people and all countries in the world. But most studies published in various global health journals, including those in our GHRP, are conducted at a local or international level. How could this global health happen?

The argument presented above leads to another conceptualization: Global health means health for a very large group of people in a very large geographic area such as the Western Pacific, Africa, Asia, Europe, and Latin America. Along with this line of understanding, an institution, a research project or an article involving multi-countries and places can be considered as global, including those conducted in countries involved in China’s Belt and Road Initiative (BRI) [ 26 , 48 , 49 , 50 , 51 ]. They are considered as global because they meet our definitions of global health which focus on medical and health issues with global impact or look for global solutions to a medical or health issue [ 5 , 7 , 22 ].

One step further, the word ‘global’ can be considered as a concept of goal-setting in global health. Typical examples of this understanding are the goals established for a global health institution, for faculty specialized in global health, and for students who major or minor in global health. Although few of the global health institutions, scholars and students have conducted or are going to conduct research studies with a global sample or delivered interventions to all people in all countries, all of them share a common goal: Preventing diseases and promoting health for all people in the world. For example, preventing HIV transmission within Wuhan would not necessarily be a global health project; but the same project can be considered as global if it is guided by a global perspective, analyzed with methods with global link such as phylogenetic analysis [ 52 , 53 ], and the goal is to contribute to global implications to end HIV/AIDS epidemic.

The concept of global impact

Global impact is a key concept for global health. Different from other public health and medical disciplines, global health can address any issue that has a global impact on the health of human kind, including health system problems that have already affected or will affect a large number of people or countries across the globe. Three illustrative examples are (1) the SARS epidemic that occurred in several areas in Hong Kong could spread globally in a short period [ 11 ] to cause many medical and public health challenges [ 54 , 55 ]; (2) the global epidemic of HIV/AIDS [ 13 ]; and the novel coronavirus epidemic first broke out in December 2019 in Wuhan and quickly spread to many countries in the world [ 56 ].

Along with rapid and unevenly paced globalization, economic growth, and technological development, more and more medical and health issues with global impact emerge. Typical examples include growing health disparities, migration-related medical and health issues, issues related to internet abuse, the spread of sedentary lifestyles and lack of physical activity, obesity, increasing rates of substance abuse, depression, suicide and many other emerging mental health issues, and so on [ 10 , 23 , 36 , 42 , 57 , 58 , 59 , 60 ]. GHRP is expecting to receive and publish more studies targeting these issues guided by a global health perspective and supports more researchers to look for global solutions to these issues.

The concept of global solution

Another concept parallel to global impact is global solution . What do we mean by global solutions? Different from the conventional understanding in public health and medicine, global health selectively targets issues with global impact. Such issues often can only be effectively solved at the macro level through cross-cultural, international, and/or even global collaboration and cooperation among different entities and stakeholders. Furthermore, as long as the problem is solved, it will benefit a large number of population. We term this type of interventions as a global solution. For example, the 90–90-90 strategy promoted by the WHO is a global solution to end the HIV/AIDS epidemic [ 61 , 62 ]; the measures used to end the SARS epidemic is a global solution [ 11 ]; and the ongoing measures to control influenza [ 63 , 64 ] and malaria [ 45 , 65 ], and the measures taken by China, WHO and many countries in the world to control the new coronaviral epidemic started in China are also great examples of global solutions [ 66 ].

Global solutions are also needed for many emerging health problems, including cardiovascular diseases, sedentary lifestyle, obesity, internet abuse, drug abuse, tobacco smoking, suicide, and other problems [ 29 , 44 ]. As described earlier, global solutions are not often a medical intervention or a procedure for individual patients but frameworks, policies, strategies, laws and regulations. Using social media to deliver interventions represents a promising approach in establishment of global solutions, given its power to penetrate physical barriers and can reach a large body of audience quickly.

Types of Global Health researches

One challenge to GHRP editors (and authors alike) is how to judge whether a research study is global? Based on the new definition of global health we proposed as described above, two types of studies are considered as global and will receive further reviews for publication consideration. Type I includes projects or studies that involve multiple countries with diverse backgrounds or cover a large diverse populations residing in a broad geographical area. Type II includes projects or studies guided by a global perspective, although they may use data from a local population or a local territory. Relative to Type I, we anticipate more Type II project and studies in the field of global health. Type I study is easy to assess, but caution is needed to assess if a project or a study is Type II. Therefore, we propose the following three points for consideration: (1) if the targeted issues are of global health impact, (2) if the research is attempted to understand an issue with a global perspective, and (3) if the research purpose is to seek for a global solution.

An illustrative example of Type I studies is the epidemic and control of SARS in Hong Kong [ 11 , 67 ]. Although started locally, SARS presents a global threat; while controlling the epidemic requires international and global collaboration, including measures to confine the infected and measures to block the transmission paths and measures to protect vulnerable populations, not simply the provisions of vaccines and medicines. HIV/AIDS presents another example of Type I project. The impact of HIV/AIDS is global. Any HIV/AIDS studies regardless of their scope will be global as long as it contributes to the global efforts to end the HIV/AIDS epidemic by 2030 [ 61 , 62 ]. Lastly, an investigation of cardiovascular diseases (CVD) in a country, in Nepal for example, can be considered as global if the study is framed from a global perspective [ 44 ].

The discussion presented above suggests that in addition to scope, the purpose of a project or study can determine if it is global. A pharmaceutical company can target all people in the world to develop a new drug. The research would be considered as global if the purpose is to improve the medical and health conditions of the global population. However, it would not be considered as global if the purpose is purely to pursue profit. A research study on a medical or health problem among rural-to-urban migrants in China [ 57 , 58 , 60 ] can be considered as global if the researchers frame the study with a global perspective and include an objective to inform other countries in the world to deal with the same or similar issues.

Think globally and act locally

The catchphrase “think globally and act locally” presents another guiding principle for global health and can be used to help determine whether a medical or public health research project or a study is global. First, thinking globally and acting locally means to learn from each other in understanding and solving local health problems with the broadest perspective possible. Taking traffic accidents as an example, traffic accidents increase rapidly in many countries undergoing rapid economic growth [ 68 , 69 ]. There are two approaches to the problem: (1) locally focused approach: conducting research studies locally to identify influential factors and to seek for solutions based on local research findings; or (2) a globally focused approach: conducting the same research with a global perspective by learning from other countries with successful solutions to issues related traffic accidents [ 70 ].

Second, thinking globally and acting locally means adopting solutions that haven been proven effective in other comparable settings. It may greatly increase the efficiency to solve many global health issues if we approach these issues with a globally focused perspective. For example, vector-borne diseases are very prevalent among people living in many countries in Africa and Latin America, such as malaria, dengue, and chikungunya [ 45 , 71 , 72 ]. We would be able to control these epidemics by directly adopting the successful strategy of massive use of bed nets that has been proven to be effective and cost-saving [ 73 ]. Unfortunately, this strategy is included only as “simple alternative measures” in the so-called global vector-borne disease control in these countries, while most resources are channeled towards more advanced technologies and vaccinations [ 16 , 19 , 74 ].

Third, thinking globally and acting locally means learning from each other at different levels. At the individual level, people in high income countries can learn from those in low- and mid-income countries (LMICs) to be physically more active, such as playing Taiji, Yoga, etc.; while people in LMICs can learn from those in high income countries to improve their hygiene, life styles, personal health management, etc. At the population level, communities, organizations, governments, and countries can learn from each other in understanding their own medical and health problems and healthcare systems, and to seek solutions for these problems. For example, China can learn from the United States to deal with health issues of rural to urban migrants [ 75 ]; and the United States can learn from China to build three-tier health care systems to deliver primary care and prevention measures to improve health equality.

Lastly, thinking globally and acting locally means opportunities to conduct global health research and to be able to exchange research findings and experiences across the globe; even without traveling to another country. For example, international immigrants and international students present a unique opportunity for global health research in a local city [ 5 , 76 ]. To be global, literature search and review remains the most important approach for us to learn from each other besides conducting collaborative work with the like-minded researchers across countries; rapid development in big data and machine learning provide another powerful approach for global health research. Institutions and programs for global health provides a formal venue for such learning and exchange opportunities.

Reframing a local research study as global

The purpose of this article is to promote global health through research and publication. Anyone who reads this paper up to this point might already be able to have a clear idea on how to reframe his/her own research project or article to be of global nature. There is no doubt that a research project is global if it involves multiple countries with investigators of diverse backgrounds from different countries. However, if a research project targets a local population with investigators from only one or two local institutions, can such project be considered as global?

Our answer to this question is “yes” even if a research study is conducted locally, if the researcher (1) can demonstrate that the issue to be studied or being studied has a global impact, or (2) eventually looks for a global solution although supported with local data. For example, the study of increased traffic accidents in a city in Pakistan can be considered as global if the researchers frame the problem from a global perspective and/or adopt global solutions by learning from other countries. On the other hand, a statistical report of traffic accidents or an epidemiological investigation of factors related to the traffic accidents at the local level will not be considered as global. Studies conducted in a local hospital on drug resistance to antibiotics and associated cost are global if expected findings can inform other countries to prevent abuse of antibiotics [ 77 ]. Lastly, studies supported by international health programs can be packaged as global simply by broadening the vision from international to global.

Is Global Health a new bottle with old wine?

Another challenge question many scholars often ask is: “What new things can global health bring to public health and medicine?” The essence of this question is whether global health is simply a collection of existing medical and health problems packaged with a new title? From our previous discussion, many readers may already have their own answer to this question that this is not true. However, we would like to emphasize a few points. First, global health is not equal to public health, medicine or both, but a newly emerged sub-discipline within the public health-medicine arena. Global health is not for all medical and health problems but for the problems with global impact and with the purpose of seeking global solutions. In other words, global health focuses primarily on mega medical and health problems that transcend geographical, cultural, and national boundaries and seeks broad solutions, including frameworks, partnerships and cooperation, policies, laws and regulations that can be implemented through governments, social media, communities, and other large and broad reaching mechanisms.

Second, global health needs many visions, methods, strategies, approaches, and frameworks that are not conventionally used in public health and medicine [ 5 , 18 , 22 , 34 ]. They will enable global health researchers to locate and investigate those medical and health issues with global impact, gain new knowledge about them, develop new strategies to solve them, and train health workers to deliver the developed strategies. Consequently, geography, history, culture, sociology, governance, and laws that are optional for medicine and public health are essential for global health. Lastly, it is fundamental to have a global perspective for anyone in global health, but this could be optional for other medical and health scientists [ 40 , 41 ].

Global Health, international health, and public health

As previously discussed, global health has been linked to several other related disciplines, particularly public health, international health, and medicine [ 3 , 5 , 7 , 18 , 22 ]. To our understanding, global health can be considered as an application of medical and public health sciences together with other disciplines (1) in tackling those issues with global impact and (2) in the effort to seek global solutions. Thus, global health treats public health sciences and medicine as their foundations, and will selectively use theories, knowledge, techniques, therapeutics and prevention measures from public health, medicine, and other disciplines to understand and solve global health problems.

There are also clear boundaries between global health, public health and medicine with regard to the target population. Medicine targets patient populations, public health targets health populations in general, while global health targets the global population. We have to admit that there are obvious overlaps between global health, public health and medicine, particularly between global health and international health. It is worth noting that global health can be considered as an extension of international health with regard to the scope and purposes. International health focuses on the health of participating countries with intention to affect non-participating countries, while global health directly states that its goal is to promote health and prevent and treat diseases for all people in all countries across the globe. Thus, global health can be considered as developed from, and eventually replace international health.

Challenges and opportunities for China to contribute to Global Health

To pursue A Community with a Shared Future for Mankind , China’s BRI , currently involving more than 150 countries across the globe, creates a great opportunity for Chinese scholars to contribute to global health. China has a lot to learn from other countries in advancing its medical and health technologies and to optimize its own healthcare system, and to reduce health disparities among the 56 ethnic groups of its people. China can also gain knowledge from other countries to construct healthy lifestyles and avoid unhealthy behaviors as Chinese people become more affluent. Adequate materials and money may be able to promote physical health in China; but it will be challenging for Chinese people to avoid mental health problems currently highly prevalent in many rich and developed countries.

To develop global health, we cannot ignore the opportunities along with the BRI for Chinese scholars to share China’s lessons and successful experience with other countries. China has made a lot of achievements in public health and medicine before and after the Open Door Policy [ 49 , 78 ]. Typical examples include the ups and downs of the 3-Tier Healthcare Systems, the Policy of Prevention First, and the Policy of Putting Rural Health as the Priority, the Massive Patriotic Hygiene Movement with emphasis on simple technology and broad community participation, the Free Healthcare System for urban and the Cooperative Healthcare System for rural residents. There are many aspects of these initiatives that other countries can emulate including the implementation of public health programs covering a huge population base unprecedented in many other countries.

There are challenges for Chinese scholars to share China’s experiences with others as encountered in practice. First of all, China is politically very stable while many other countries have to change their national leadership periodically. Changes in leadership may result in changes in the delivery of evidence- based intervention programs/projects, although the changes may not be evidence-based but politically oriented. For example, the 3-Tier Healthcare System that worked in China [ 79 , 80 ] may not work in other countries and places without modifications to suit for the settings where there is a lack of local organizational systems. Culturally, promotion of common values among the public is unique in China, thus interventions that are effective among Chinese population may not work in countries and places where individualism dominates. For example, vaccination program as a global solution against infectious diseases showed great success in China, but not in the United States as indicated by the 2019 measles outbreak [ 81 ].

China can also learn from countries and international agencies such as the United Kingdom, the United States, the World Health Organization, and the United Nations to successfully and effectively provide assistance to LMICs. As China develops, it will increasingly take on the role of a donor country. Therefore, it is important for Chinese scholars to learn from all countries in the world and to work together for a Community of Shared Future for Mankind during the great course to develop global health.

Promotion of global health is an essential part of the Working Together  to Build a Community of Shared Future for Mankind. In this editorial, we summarized our discussions in the 2019 GHRP Editorial Board Meeting regarding the concept of global health. The goal is to enhance consensus among the board members as well as researchers, practitioners, educators and students in the global health community. We welcome comments, suggestions and critiques that may help further our understanding of the concept. We would like to keep the concept of global health open and let it evolve along with our research, teaching, policy and practice in global health.

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Acknowledgements

We would like to thank those who had provided their comments for the improvement of the manuscript.

The work is funded by the journal development funds of Wuhan University.

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Xinguang Chen, Hao Li, Xiaohui Liang, Zongfu Mao, Nan Wang, Peigang Wang & Tingting Wang

Department of Epidemiology, University of Florida, Florida, USA

Xinguang Chen

School of Health Sciences, Wuhan University, Wuhan, China

Hao Li, Xiaohui Liang, Zongfu Mao, Nan Wang, Peigang Wang, Tingting Wang, Hong Yan & Yuliang Zou

Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK

Don Eliseo Lucero-Prisno III

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Abu S. Abdullah

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Chen XG wrote the manuscript. LI H organized the meeting, collecting the comments and editing the manuscript. Lucero-Prisno DE integrated all the comments together. Abdullah AS, Huang JY, Laurence C, Liang XH, Ma ZY, Ren R, Wu SL, Wang N, Wang PG and Wang Tt all participated in the discussion and comments of this manuscript. Laurence C and Liang XH both provided language editing. The author(s) read and approved the final manuscript

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Chen, X., Li, H., Lucero-Prisno, D.E. et al. What is global health? Key concepts and clarification of misperceptions. glob health res policy 5 , 14 (2020). https://doi.org/10.1186/s41256-020-00142-7

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Reimagining the Future of Global Health Initiatives: Final Report Release

30/08/23 News

We are thrilled to announce the release of the final report from our research project, “ Reimagining the Future of Global Health Initiatives .” This report delves deep into the intricate world of Global Health Initiatives (GHIs), offering invaluable insights into their trends, challenges, and positive contributions that are shaping the global health landscape.

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In an ever-evolving world, the realm of global health is marked by both opportunities and complexities. Our report takes a closer look at the dynamic trends that are shaping the future of global health initiatives. From innovative financing strategies that are revolutionizing healthcare funding to unforeseen outcomes that have sparked new discussions, this report is a treasure trove of knowledge for those invested in the world of health.

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A reflection on global health in 2020 from our director, dr. michele barry.

Published: 01/10/2021

Dear Global Health Colleagues,

When one works in global health, one spends time thinking about what a global pandemic would look like. We have seen epidemics and spillover of zoonotic pathogens to humans, and we have even lived through pandemics before. We have pointed to data and disturbing trends, issued warnings, given talks, and yet despite it all, when our new reality began to take shape early this year, it was as startling to me and my fellow colleagues as it was to everyone else. I am currently reading a wonderful book called  The Splendid and the Vile  by Eric Larsen about Churchill and the bombing siege on London — the analogy to the siege and lockdown we are living through is stunning. The Stanford Global Health community rapidly swallowed their astonishment and took the crisis head on, and while COVID-19 has been an all-consuming threat, I am also proud to report that we have addressed it without forgetting the many other ongoing struggles in global health. Enormous achievements have been made this year by our 170 Global Health Faculty Fellows, global health researchers, and committed students. Though I wish I could highlight them all, I would like to share a few achieved concurrent with pandemic efforts. Kudos to those who have persisted in their efforts in Human and Planetary Health, correcting and better understanding environmental degradation and its immense consequences for human health. Stanford faculty have made immense gains in this field, from our expanded understanding of mosquito borne illnesses from Global Health Faculty Fellows  Desiree LaBeaud  and  Erin Mordecai , which stands to save lives around the world, to doctors  Kari Nadeau and Mary Prunicki’s  research and communications on the health impact of wildfires. Stanford researchers from Disease, Health, and Ecology and myself presented evidence from Borneo on how  accessible healthcare can curb deforestation , and Stanford Global Health Director of Research Steve Luby has advanced our understanding of the dangerous  Nipah virus  and it’s zoonotic transmission potential. Even our students have demonstrated passion and a zeal for results, planning and implementing the  Norcal Symposium on Climate and Pandemic Resilience in Healthcare.  And looking forward, I am excited that Stanford Global Health Senior Advisor, Diana Walsh will be moderating a panel with the Dalai Lama and Greta Thunberg on the climate crisis on January 9 th  — please  register here  to attend this special event. Kudos to those who have advocated for gender parity, especially women’s careers in global health. The  WomenLift Health  team of our  Center for Innovation in Global Health  oversaw a flourishing cohort in their  Leadership Journey  and successfully hosted the  2020 Women Leaders in Global Health Conference  with over 2,300 participants from around the world. Contributions to this growing effort are widespread amongst our faculty and even beyond. A new Global Center for Gender Equality is being formed by Gary Darmstadt and Sarah Henry. However, in a  Lancet correspondence  from Global Health Resident Brooke Gabster and myself, we sadly documented a dramatic drop in authorship for the female academic during COVID-19. And I am proud of the great efforts our community has made towards health equity. While there is much work to do in this area beyond COVID-19, the virus magnified existing health disparities around the world. The Stanford Global Health community rose to the occasion, from  open-source PPE resources  to  serving critical roles in migrant health  along the U.S. – Mexico border, like Faculty Fellow Paul Wise, who continues to serve as the special expert for the U.S. Federal Court  overseeing the treatment of migrant children . Faculty Fellows S.V. Mahadevan and Matthew Strelow shared COVID-19  treatment protocols  with global healthcare providers by partnering with digitalMEdiC early in the pandemic, while others like Dr. Jason Andrews quickly took action to prevent  disastrous outbreaks in U.S. prisons . Meanwhile, we are proud to have swiftly  seeded six research  grants to combat COVID-19, and partner with the Pine Ridge Reservation to assist them in preparing for an anticipated surge; Faculty Fellows  Ana Crawford  and Ewen Wang continue to provide support to this effort.   During a time when global health has never been more front-and-center to public view, there are myriad examples of courage, ingenuity, and stalwart leadership. The successful global effort to create not just one viable vaccine, but many, has been astonishing. As I write this, many of my colleagues are receiving safe and effective vaccines less than a year after the first case was observed, colleagues who have put themselves in harm’s way to continue treating patients. This accomplishment is an unrivaled testament to what we can do with aligned intent, scientific discovery, innovation, and political will.

This year we have witnessed harsh and daunting realities, from failing health systems, to flagrant systemic racism and gaping health disparities. With a newfound sense of what is possible (and great hopes for a new U.S. administration to boot), we need to keep these issues in the limelight. Let us leave this year behind us with the thought that we can rise to global health challenges such as COVID-19 and still work towards the health of our planet and equity of its inhabitants. Finally, thank you to the dedicated and hard-working teams at the Center for Innovation in Global Health and WomenLift Health, as well as the larger Stanford Global Health community. Your efforts and resolve never fail to amaze me. Pax — and health in the new year, Michele Barry

Drs. Ben and A. Jess Shenson Professor of Medicine and Tropical Diseases Director of the Center for Innovation in Global Health Senior Associate Dean for Global Health, Stanford University

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FACT SHEET: Global Health Worker Initiative (GHWI) Year Two Fact   Sheet

As we celebrate two years since the launch of the Global Health Worker Initiative (GHWI), the United States continues to demonstrate our commitment to global health and to the global health workforce, providing more than $10.5 billion in global health program funding with Fiscal Year (FY) 2023 funds. Recognizing that strategic and sustained investments in health workers are critical to overcoming the setbacks from COVID-19 and to achieving sustained progress toward the Sustainable Development Goals (SDGs), the United States contributes more than $1.5 billion annually to support health workers and strengthen the health workforce globally through our bilateral health programs, such as the President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. President’s Malaria Initiative (PMI), and global health security programs. For the first time in FY24, USAID is receiving $10 million in new funding to support the GHWI and the President’s 2025 Budget requested $20 million to build on this important work.   All countries, including the United States, must take action now to be prepared for the next pandemic and to achieve the health-related SDG targets, which include ending HIV, tuberculosis (TB), and malaria as a public health threat by 2030, achieving universal health coverage and access to essential health services, and preventing child and maternal deaths.   Health care workers need safe, healthy, supportive working environments to do their jobs – yet across the globe, health workers have to operate in increasingly difficult, even dangerous conditions with limited protections of their rights. Far too many health workers face inadequate pay, safeguards, and equipment, and lack access to mental health and psychosocial support services, and, in many cases, health workers face harassment and violence with targeted attacks on the rise. These challenges have a disproportionate impact on women, who represent 70% of the health workforce, which further hinders women’s economic security.     Through the GHWI, the United States has partnered with countries and communities around the world to support efforts to build a stronger health workforce and make health workers safer and better equipped to provide high-quality care. 

  PILLAR 1: PROTECTING AND SUPPORTING HEALTH WORKERS The United States has invested in efforts to protect and support health workers around the world so that they can continue providing services safely while also taking care of their well-being.  

• The United States supports global efforts to monitor a growing number of attacks on health workers.  The U.S. Agency for International Development (USAID) supported the operation of the World Health Organization’s (WHO) Surveillance System for Attacks on Health Care (SSA) to document and disseminate data on attacks on health workers across countries experiencing complex humanitarian emergencies.  Since January 1, 2024, this WHO website has documented 395 attacks in 12 countries and territories, resulting in 160 deaths and 267 injuries of health workers. 
• The United States is supporting efforts to address workplace safety concerns in health settings.  In Ukraine, over the past year, USAID has helped safeguard health workers while maintaining access to health care following the Russian invasion through adoption of innovative telemedicine solutions, including the training of 724 health and information technology workers and the facilitation of 2,130 technical support sessions. As a result, health workers have provided over 10,000 telemedicine visits following the training.  In addition, the CDC supported training of laboratory staff in infection prevention and control (IPC) practices in Uganda, upgraded and certified biosafety cabinets in Senegal, and supported disease-specific testing for numerous disease outbreaks, including support for molecular serotype testing for dengue during an active outbreak in Bangladesh.

PILLAR 2: EXPANDING THE GLOBAL HEALTH WORKFORCE AND ACCELERATING ECONOMIC DEVELOPMENT The United States is continuing efforts to create career pathways, improve labor protections, and expand opportunities for paid employment for health workers, including community health workers to address systemic barriers and to close critical skill gaps.

• The United States has launched new effort to improve working conditions and encourage fair labor standards.  Through USAID’s Gender Equity and Quality (GEEA) Fund, USAID established its first partnership with a global union federation to advance the representation and rights of health and care workers. This multi-country activity strengthens health and care workers’ organizations, and health worker leaders that advocate for improved working conditions, safeguards, and equitable employment in Colombia, Dominican Republic, Ghana, and Philippines. This work advances women’s economic security by addressing key barriers that disproportionately impact women who are more likely to be employed in the health sector, by encouraging fair labor standards and social protections.   In addition, USAID, together with UNICEF, WHO and other global and regional partners, launched the Community Health Delivery Partnership (CHDP) to build a common country-led, data-driven agenda to improve alignment, high-level advocacy, and accountability focusing on community health workers’ status, rights, and protections. To date, the partnership has mobilized over 500 participants from Bangladesh, Ethiopia, Kenya, Liberia, Malawi, Uganda, and Philippines.
• The United States provides critical support to health workers who provide essential HIV, TB, and malaria services.  PEPFAR helps fund salaries for critical health staff in more than 55 countries where the United States supports the expansion and continuation of HIV and TB services—this includes more than 346,000 doctors and medical officers, nurses and midwives, social workers, laboratory staff, pharmacists, public health professionals, and community health workers and other community-based cadres.  PEPFAR also supports health workforce management and policies, health workforce training, recruitment, and retention, and human resources information systems.  Over the past year, PMI provided training, supervision, and equipment to approximately 100,000 community health workers across Africa and southeast Asia. This support enables community health workers to deliver case management of malaria at the community level, most often through integrated platforms that enable treatment of other common childhood illnesses such as diarrhea and pneumonia.
• The Peace Corps, through its Advancing Health Professionals (AHP) Program , has recruited and deployed U.S. health professionals to (1) train health workers in clinical pharmacy and pharmacognosy at the University of Malawi College of Medicine;  (2)  provide training in medical-surgical nursing  to third-year nursing students to advance the primary health care (PHC) system in Uganda; (3)  design the Emergency Medical Care (EMC) professional courses curriculum for undergraduates in Eswatini; (4) train nurse practitioners to treat more complex diseases (through task shifting) in Liberia; and (5) train local providers of HIV treatment for indigenous populations in Panama.
• Skilled public health workers are essential to rapidly detect and respond to disease outbreaks. CDC’s Field Epidemiology Training Program (FETP) builds global health workforce capacity in countries around the world by better equipping health workers to meet population health needs. When avian influenza A H5N1 resurfaced in 2023, CDC’s FETP-trained health workers in Cambodia swiftly joined an international investigation team from various sectors, including the World Health Organization (WHO) and United Nation’s Food and Agriculture Organization (FAO), to address this highly pathogenic virus of international concern.  Their expertise played a pivotal role in the rapid response and implementation of disease control measures during the outbreak, underscoring the critical contribution of health workforce development programs to global health security and improving health threat management on a global scale. 
• The United States is working to ensure that a strong health workforce is part of building a strong primary health care system.  Through Primary Impact, USAID is working to accelerate essential health care provision by supporting country-led plans to strengthen primary health care and investing in the health workforce in seven countries, including Nigeria, Côte d’Ivoire, Ghana, Malawi, Kenya, Indonesia and the Philippines.  In early 2024, Primary Impact programs expanded to India, Madagascar, Rwanda, Uganda, and Vietnam.  In Kenya, USAID has supported the establishment of 108 Primary Health Care Networks across 25 counties, supporting the rollout of multidisciplinary health teams and a new community health promoter cadre who are equipped with digital devices that link to an electronic community health information system. 
• CDC supports the Stop Transmission of Polio (STOP) Program , in collaboration with WHO and UNICEF to augment and build capacity of the immunization workforce in the most difficult settings. This program recruits and trains international public health experts and deploys them to countries around the world to strengthen national immunization surveillance programs, support supplemental immunization activities, respond to disease outbreaks, and help support polio eradication. During the past year, CDC trained and deployed 61 experts, while also supporting the activities of an additional 120 experts already trained and deployed in 32 countries. 

PILLAR 3: ADVANCING EQUITY AND INCLUSION Over the past year, the United States has supported efforts to build a more diverse health workforce and health leadership and advance training opportunities for career growth and workforce retention. This has included increasing partnerships and efforts to build capacity for the roles of local community and faith-based organizations as service providers to populations that are under-served and most vulnerable. 

• The United States has increased its investment in nurses, who serve as the backbone of patient care.  In March, PEPFAR launched a Nursing Leadership Initiative in Botswana, Côte d’Ivoire, Eswatini, Malawi, Nigeria, South Africa, and Zambia. Through the initiative, PEPFAR is providing $8 million in 2024 to support nurses at the forefront of the HIV/AIDS response. This initiative aims to: (1) enhance nurses’ skill sets to lead planning and delivery of HIV/AIDS-related services; (2) help nurses to identify, advocate, and leverage innovative digital solutions to enhance quality service delivery; (3) protect nurses by enhancing their infection prevention and control skills, providing supportive work environments, and supporting mental health needs; (4) invest in the development, retention, and equitable distribution of the nursing workforce; and (6) enhance nurses’ communications and leadership skill sets. 
• The United States builds capacity of community and faith-based partners who play a critical role in the delivery of health services.  Through New Partnerships Initiatives (NPI) investments, USAID worked with local community and faith-based partners in Pakistan, Malawi, South Sudan, Kenya and Haiti to train community health workers and volunteers to conduct community outreach to advance social and behavior change among youth, women and men in underserved and hard-to-reach communities. Community health worker and volunteer efforts led to improved community awareness of available services and increased use of locally available family planning and maternal health services. 
• The United States has partnered with HBCUs to train at-risk adolescents to work in health-related fields. The Department of Health and Human Services (HHS) in partnership with Historically Black Colleges and Universities Global Health Consortium (HBCU GHC), partnered with the Government of Malawi to train and employ adolescent girls and young women (AGYW) as Disease Control Surveillance Assistants.  With funding from PEPFAR, this partnership has recruited and trained 220 graduates of the DREAMS Program for AGYW from the three districts with the highest rates of new HIV infections among AGYW – 98 percent of these graduates have been retained and are currently employed providing essential primary health and HIV services with a special focus on AGYW health needs. 
• The Department of Defense has worked to combat stigma and discrimination in military health services.  Since 2018, the Department of Defense HIV/AIDS Prevention Program (DHAPP) has led a comprehensive initiative to combat stigma and discrimination in military health services across over 30 countries. This effort has resulted in the establishment of Codes of Conduct in more than twenty Ministries of Defense (MOD) Health Facilities, driving policy adjustments within MODs to enable service members to serve and deploy on Peacekeeping Missions without bias. With DHAPP’s support, healthcare workers are now providing stigma-free healthcare, fostering inclusivity and support within both military and civilian communities.  
• The United States is training health workers in equity research. As the largest funder of health research in the world, the National Institutes of Health (NIH) has trained more than 7500 researchers in more than 130 countries since 1989 through the Fogarty International Center (FIC).  In the past year, NIH has supported neurology research in Zambia and 8 centers to undertake collaborative cancer research through the Global Training for Research and Equity in Cancer program.  Research training topics include cancer genetics, epidemiology, bioinformatics, clinical research, and implementation research.

PILLAR 4: DRIVING AND INVESTING IN TECHNOLOGICAL ADVANCEMENTS AND INNOVATION Over the past year, the United States has continued to expand digital strategies that equip health workers to provide more efficient, quality-integrated service delivery, including telehealth services that can expand the reach of health services to remote, underserved and marginalized communities.

• CDC has developed two health informatics training programs: GEEKS (Growing Expertise in E-Health Knowledge and Skills), a tiered training to apply skills to improve vaccine coverage and strengthen disease surveillance systems; and I-LEAD (Inter-governmental Learning Exchange to Advance Data-Driven Decision-Making), a leadership program that enables participants to develop and implement digital health solutions.  Over the past year, GEEKS has trained more than 400 participants and implemented 29 projects, while I-LEAD has trained more than 194 participants from 20 countries.   
• PMI invests in digital decision-making and data-collection tools for community health workers. These tools can improve the quality of care and job performance by health workers while generating data to identify underserved populations, document program impact on morbidity and mortality, and better forecast commodity needs. Through PMI’s digital community health initiative, digital community health assessments were conducted in 27 PMI partner countries. During the past year, activities identified in these initial assessments were implemented in 8 countries, including support for a community electronic medical record system in Rwanda and a community health worker registry in Zambia.
• Virtual learning strategies can now reach the most difficult and remote settings. The United States has supported Project ECHO, a model in which health workers participate in a virtual community of practice with their peers where they share knowledge, experience and feedback. Project ECHO has programs in more than 80 countries with attendees in many more and has reached more than two million health workers with these trainings.  While these efforts started prior to the COVID-19 pandemic, Project ECHO provided an essential lifeline when many countries were locked down, and this initiative has continued to expand post-COVID. In many settings, virtual engagements have replaced or augmented costly in-person trainings, and the model has well-demonstrated impact.  For example, the Department of Defense HIV/AIDS Prevention Program (DHAPP) supports Project ECHO in 46 countries, including advanced clinical HIV training sessions in 16 countries.  U.S. agencies have also funded Project ECHO to train health workers on COVID-19, public health emergency management, tuberculosis (TB), One Health, infection prevention and control, antimicrobial resistance, and laboratory skills.

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“The Doctor as a Humanist”: The Viewpoint of the Students

Conference Report and Reflection by Poposki Ognen (University Pompeu Fabra); Castillo Gualda Paula (University of Balearic Islands); Barbero Pablos Enrique (University Autonoma de Madrid); Pogosyan Mariam (Sechenov University); Yusupova Diana (Sechenov University); and Ahire Akash (Sechenov University)

The practice of Medicine as a profession has become very technical; doctors rely on fancy investigations, treatment algorithms and standardized guidelines in treating patients. In a lot of universities, medical students and residents are trained without appreciating the importance of art and the humanities in delivering good care to patients and their families. Factual knowledge is imposed on us, as students, from scientific evidence delivered by highly specialized professionals: those who know more and more about niche subjects.

As a result, when someone decides to become a doctor , it seems that scientific training is the sole priority, with most attention being given to the disease-treatment model. As medical students, we are taught very specific subjects, leaving little or no space or time for any cultural enrichment programs. And yet, Personal growth as a doctor and a human being cannot be achieved unless one is exposed to the whole range of human experience. Learning from art and artists can be one such means of gaining these enriching experiences. We can learn from historians, and from eminent painters, sculptors, and writers, as well as from great scientists. How do we achieve these ends? The following essay summarizes and reviews one attempt at providing answers. The 2nd “Doctor as a Humanist” Symposium took place at Sechenov University in Moscow from the 1 st to the 3 rd of April, 2019, to explore the holistic perspective of interpersonal treatment.

To begin our essay, we would like to clarify some key concepts, such as culture, humanism and humanities, as they were employed at the conference. Culture is a complex phenomenon that includes knowledge, beliefs, artistic production, morals, customs and skills acquired by being part of a society, which can be transmitted consciously or unconsciously, by individuals to others and through different generations.

The humanities are academic disciplines that study the cultural aspects and frailties of being human, and use methods that are primarily analytical, critical, or speculative, which distinguish them from the approaches of the natural sciences. Humanism is the practice of making the human story central. Consequently, the studies of humanities, so invested in human stories, is one aspect of practicing humanism.

Technological and practical progress in medicine has been impressive in the past fifty years. Nevertheless, patients still suffer from chronic conditions such as heart failure, chronic lung disease, depression, and many others. These are conditions where technology cannot significantly change the outcomes or reverse the underlying condition. One of the ways to alleviate suffering is through compassion and empathy where the doctor is a professional who listens to, understands and comforts the patient, as well as engaging the patient as a fellow human being. We need arts and humanities as doctors’ tools to comfort and, perhaps, even to heal. We also need them to remind us that we are ‘merely human’ ourselves, and that we share our humanity with our patients, as equals.

Unquestionably, there are fundamental requirements that every physician must internalize; the conference goal was to explain that one such requirement is the humanistic view. Opera, poetry, philosophy, history, the study of dialectics, biographical readings, and even volunteering abroad can be means of engaging the world for positive change. Sometimes called  “soft” skills, these are in fact necessary and valuable qualities to empower ourselves as persons, as well as doctors. The 2nd The Doctor as a Humanist Symposium placed the corner stone in a global project that aims to understand medicine as a multidisciplinary subject, and to establish the concept of humanistic medicine both as a science and an art where the patient and the doctor are human beings working together.

STUDENT PARTICIPATION

The event united experts in Medicine and the Humanities from all over the world. The speakers (doctors, nurses and students) were from Russia, the USA, the UK, Spain, Italy, Germany, Mexico and more. Each day’s program was both intense and diverse, and included plenary lectures and panel sessions. Medical students were highly involved in all parts of the conference, offering us a great chance to introduce our projects, share our opinions on various topics, and discuss our questions connected with the role of the humanities in medicine.We participated in roundtable discussions, which were chaired by experts from different countries. Even though this made us nervous, at the same time it was very important for us, as students, to be a part of it. We discussed the future of medical humanities from various perspectives, and above all our thoughts and ideas were listened to and commented on, on an equal basis with the world’s experts. For once, we could see that our views were being taken into consideration, and we hope that in the future this will be the norm and NOT the exception. We are the future of medicine, and our voices should be heard, too.

At the end of the first day there was a students’ session, where we gave our opinions on the relative importance of the medical humanities from a multicultural viewpoint, and on this particular roundtable there were students from Russia, Spain, Iran, Mexico, Italy, as well as a Nursing resident. One of the students during the session shared her view that “I would like to see medicine through the lens of humanism and empathy, and also implement all its principles in my professional life on a daily basis”. All participants agreed, and although we were representing different countries and cultures there was no disagreement about this. Even though we have not yet faced many of the obstacles of the world of medicine, we can see the role of compassion in clinical practice better perhaps than our seniors. We shared our points of view about this question and its relevance in the different countries. It was an incredible moment, as experts and professors demonstrated a great interest in our ideas.

The program was extremely diverse; however, the main idea that most speakers expressed was how to find, sustain and not lose humanist goals. Brandy Schillace gave an impressive presentation entitled “Medical Humanities today: a publisher’s perspective”, which studied the importance of writing and publishing not only clinical trials, but also papers from historians, literary scholars, sociologists, and patients with personal experiences. The nurses Pilar d’Agosto and Maria Arias made a presentation on the topic of the Nursing Perspective that is one of the main pillars of medical practice. Professor Jacek Mostwin (Johns Hopkins University) shared his thoughts on patients’ memoirs. An Italian student, Benedetta Ronchi presented the results of an interview on medical humanities posed to the participants and speakers during the symposium. The plurality of perspectives made this conference an enriching event and showed us how diverse ideas can help us become better doctors. More importantly, it reminded us of our common humanity.

A significant part of the symposium was dedicated to Medicine and Art. Prof Josep Baños and Irene Canbra Badii spoke about the portrayal of physicians in TV medical dramas during the last fifty years. The book “The role of the humanities in the teaching of medical students” was presented by these authors and then given to participants as gifts. Dr Ourania Varsou showed how Poetry can influence human senses through her own experience in communicating with patients. She believed that many of the opinions and knowledge that we have internalized should be unlearned in order to have a better understanding of the human mind. The stimulus of poetry makes this possible. Poetry allows us to find new ways to express ourselves, and thus increase our emotional intelligence and understanding of other people’s feelings.

One of the most impressive lectures was by Dr Joan.B Soriano, who spoke about “Doctors and Patients in Opera” and showed how the leading roles of physicians in opera have changed over the centuries. People used to consider the doctor as the antihero, but with time this view has transformed into a positive one that plays a huge role in history.

It is important to be professional in your medical career, but also to be passionate about the life surrounding you; for instance, Dr Soriano is also a professional baritone singer. For students, this Symposium was full of obvious and hidden messages, which gave us much lot of food for thought. As Edmund Pellegrino, the founding editor of the Journal of Medicine and Philosophy , said: “Medicine is the most humane of sciences, the most empiric of arts, and the most scientific of humanities.”

CHOOSING ONE WORD

To conclude our summary of the students’ viewpoint each of us chose One word to encapsulate our thoughts about the symposium.

The Doctor as a Humanist is a multicultural event where everyone can learn and contribute to this global necessity to put the heart and soul back into medicine. Of course, we are aware and delighted that other organizations are championing the cause of the Humanities in Medicine, and in some cases, such as https://www.dur.ac.uk/imh/ , they have been doing so for many years.

As medical students, we appreciate how we have been placed at the centre of the symposium, which we believe has made this new initiative rather special. We hope that students of Medicine and from other disciplines come and participate in future symposia.

If you want to learn more, and see how you can participate, please contact the International student representatives, Mariam ( [email protected] ) and David ( [email protected] ).

Acknowledgements

Assistance provided by Jonathan McFarland (c) and Joan B. Soriano (University Autonoma de Madrid) was greatly appreciated during the planning and the development of the article.

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The World Health Organization and global smallpox eradication

Background:.

This article examines the multifaceted structures and complex operations of the World Health Organization and its regional offices; it also reassesses the form and the workings of the global smallpox eradication programme with which these bodies were closely linked in the 1960s and 1970s.

Using the case study of South Asia, it seeks to highlight the importance of writing nuanced histories of international health campaigns through an assessment of differences between official rhetoric and practice.

Results and conclusion:

The article argues that the detailed examination of the implementation of policy in a variety of localities, within and across national borders, allows us to recognise the importance of the agency of field managers and workers. This analytical approach also helps us acknowledge that communities were able to influence the shape and the timing of completion of public health campaigns in myriad ways. This, in turn, can provide useful pointers for the design and management of health programmes in the contemporary world.

The global eradication of smallpox was certified by an independent committee of experts in December 1979, and the announcement was ratified by the World Health Organization (WHO) in 1980. Widely hailed as one of the biggest medical triumphs of the twentieth century, the campaign to eradicate smallpox worldwide is often described in overly simplistic terms in institutional histories, published memoirs and, not least, academic works that unquestioningly accept participants’ retrospective retelling of their experiences. The picture presented, generally, is one of unified actions; the many different cogs of a complex administrative wheel, it is frequently claimed, apparently worked in almost perfect unison, causing orders from the top of the organisational pyramid to be implemented in localities across the globe. Such an interpretation would have us believe that the calculations and actions of a few senior managers controlled the actions of a huge number of public health and medical personnel of different educational backgrounds, nationalities, political affiliations and gender, over the course of more than a decade. This perspective downplays the ability of field workers to come up with ideas and implement them according to the plethora of social, political and economic conditions encountered in a multiplicity of localities. 1 – 3

The organised drive to expunge smallpox was, however, a much more complicated and disjointed entity. A composite of numerous multifaceted country- and region-oriented public health programmes, the campaign combined the work of several non-government agencies with that of different national, provincial and district administrations. A careful assessment of unpublished WHO papers reveals that these collaborative ventures involved a series of time-consuming negotiations with numerous bureaucrats, politicians and funding agencies. This, in turn, resulted in complex administrative and financial arrangements that needed to be re-established at frequent intervals; a product of the fact that inter- and intra-governmental discussions and the resulting aid packages, which were to prove decisive to the successful completion of smallpox eradication, were frequently organised on varying bilateral and multilateral bases. WHO officials were generally involved in multilateral negotiations, as initiators of negotiations, witnesses to the completion of signed agreements and, sometimes, apolitical distributors of resources in the shape of vaccine, vaccinating kits, money and personnel. 4

Yet, these WHO representatives were often not in control of the unfolding of policy imperatives, mainly because a variety of international, regional, national and local developments continually threatened to blow the most tightly organised plans off course. Projects often stuttered along uncharted paths, as their managers were constantly forced to adapt to unexpected problems. Because of this, desired results were frequently achieved almost accidentally, surprising even the most optimistic and committed field personnel. An appreciation of all these complexities, which are very often glossed over, does not detract from the significance of the smallpox eradication. To the contrary, it highlights the enormity of the achievement, which many officials and politicians considered impossible during the 1960s and 1970s. 4 5

THE ADMINISTRATIVE COMPLEXITY OF THE WHO

The United Nations came into being soon after the end of the Second World War, and the WHO was established as one of its major, specialised sections in 1948. The WHO headquarters (HQ) was established in Geneva, Switzerland, and this body took on the role of trying to help in the development and coordination of public health and medical schemes across the globe. In its formative years, these activities were targeted particularly at regions that had been badly affected by the war and countries that had managed to break loose from colonialism; the advertised goal was to carry out all this work on an apolitical basis. 6 7

The WHO has, from its inception, been a complex administrative structure. It consists of a Health Assembly, a Director General’s office that is in regular touch with a relatively tightly knit advisory committee and, not least, a large secretariat. The Assembly was formed by representatives of all the member nations, who met at regular intervals in Geneva and involved themselves in proposing schemes and voting for their implementation. This body was given the power, through the WHO constitution, to ask the Director General’s office and his/her advisory committee to develop detailed plans for the implementation of policies and programmes; all completed plans were presented to the assembly and then forwarded to the secretariat’s bureaucracy for implementation. This, in turn, ensured the formulation of numerous plans within the WHO HQ and the various WHO regional offices, as workers associated with these bodies, with different types of training, specialisation and institutional affiliation, frequently came up with varying ideas about how best to achieve different goals. 6

To add to the complexity of what was really the first stage of policy implementation, departments within the different WHO offices would also often set up—on a collaborative basis or otherwise—specialist research groups to provide blueprints for action. These suggestions, which were often published as so-called technical reports, did not automatically become ordained as WHO blanket policy; instead, organisational representatives in the field were often directed by WHO office managers to give greater attention to some proposals than others, as a variety of political and economic considerations had to be made part of the larger calculations of designing and implementing policy. A further layer of operational complexity was added by the experiences of field personnel, who had to work in a variety of regional, national and local contexts. Indeed, as these officials—of different nationalities, races, gender and educational profile—adapted to a variety of political, economic, social and medical situations, they were forced to reinterpret centrally dictated policies in numerous ways. In doing this, it is striking that WHO field officials were continually forced, sometimes to their displeasure, to draw upon local sources of information and help. This assistance was generally sought from among local political structures and sections of the social groups at whom different public health policies were being targeted. This local knowledge and the resultant activities were, of course, not always in concert, as varying interests competed for recognition and precedence, adding several layers of operational complexity to the unfolding of public health and medical campaigns. 4

It is worth noting here that all the WHO regional offices, their departments and the country representatives within them were important actors in the formulation and implementation of policy in the field. This has been ignored in most academic studies, which tend to focus on either the voices of a handful of people based in Geneva or the Health Assembly’s resolutions published by the WHO HQ after several rounds of careful editing. This also perhaps explains why the significant voices of national- and local-level staff, usually employed by different WHO offices on short-term contracts of varying lengths, is almost entirely lost in historical writings dealing with different health programmes. 8 This is a serious lacuna, as the opinions and actions of such staff, who were usually in touch with local politicians and bureaucrats, acting as crucial links between them and a range of international WHO workers on a day-to-day basis, are a crucial element in projects sponsored, managed or encouraged by both the WHO HQ and regional offices. Getting access to these significant voices is difficult, requiring concerted archive research and a willingness to chase down personal papers and talk to WHO workers of all grades (sometimes in languages other than English). However, such difficulties should not be used by historians as a justification for the preparation of blinkered studies denying agency to all but a handful of senior WHO administrators.

SOUTH ASIAN NATIONAL SMALLPOX ERADICATION PROGRAMMES

The WHO’s World Health Assembly (WHA) started considering the prospect of eradicating smallpox worldwide in early 1950—discussions on the topic were held within the WHA that year, and in 1953, 1954 and 1958. Indeed, Dr Brock Chisholm, the WHO’s first Director General, proposed global smallpox eradication in 1953, even if these discussions did not progress particularly far. Noticeable progress on the issue was witnessed at the 11th WHA, which was held in Minneapolis, USA, in 1958, where Professor Viktor Zdhanov, the USSR Deputy Minister of Health, argued that the eradication of the variola virus was theoretically possible and important to the world as a whole, including countries that had managed to expunge the disease within their territories. His views—and the proposal put forward by him in the shape of what is often referred to as the “Zdhanov resolution”—received broad-based support at the gathering, leading the WHO’s Executive Board to meet immediately after the WHA and announce preparations for a future smallpox eradication drive. In Geneva, this took the shape of the acceptance of donations of freeze-dried smallpox vaccine from the USSR and glycerolated vaccine from Cuba, which was used to create an “account” that would distribute stocks to countries where eradication campaigns were initiated; the decision also resulted in discussions with officials based in the WHO regional offices and national governments in charge of smallpox endemic territories. 2

The relatively small number of WHO officials who started discussing the prospects of global eradication of smallpox in the early 1960s very much hoped that it would be a top–down campaign, wherein the WHO HQ in Geneva—and, particularly, some departments within it—would be able to set a general campaign agenda. Recommendations were, for instance, volunteered in relation to how immunisation might be carried out, what sort of vaccines to use and how to assess the achievement of eradication. However, their experience quickly revealed the pitfalls of believing that they could automatically assume such intellectual and technical leadership. Representatives within the WHO regional offices raised numerous queries about proposals sent in from Geneva, and highlighted their own firmly held belief that all central directives would require tailoring to fit local conditions. These features of “locality” were presented as being challenging and inconstant, which, in turn, it was argued, meant that programme implementation would require frequent re-jigging, as political arrangements with different national governments were set up, reconfigured or abandoned. Significantly, similar trends remained visible after 1967, when the WHO’s Health Assembly formally signed up, with great fanfare, to the goal of global smallpox eradication. 4

There were disagreements, too, at other administrative levels about how a global campaign to eradicate variola might be organised and run. Plans that were presented as a good idea by one group of WHO workers at one regional office were almost routinely challenged within their organisation and outside. Criticism from within other regional offices was often quite strident, as officials based therein made it a point to underline the need to develop locally specific plans. And as the scope of what was defined as constituting the “locality” expanded from government structures located within specific national capitals to the political and social constituencies of the districts, subdivisions and villages within whose administrative confines immunisation policies were actually going to unfold, the disagreements within the complexity of WHO structures became even more marked. 9

The South Asian subcontinent, which was the focus of the global eradication programme in the late 1960s and the 1970s owing to the high incidence of variola in the region, was a good case in point. WHO officials in touch with representatives of the Indian, Pakistani, Nepali, Sri Lankan, Bhutanese, Burmese and, later, Bangladeshi national governments—and, therefore, keenly aware of the many expectations and tensions within those multifaceted formations—refused to blindly accept orders relating to the blanket implementation of specific immunisation strategies and vaccine usage patterns coming in from Geneva. Strikingly, suggestions from the HQ were frequently queried and discussions were held within the regional offices about how the dictates from Geneva might be restructured to best meet a host of local needs. These trends were very noticeable within the Eastern Mediterranean Regional Office (EMRO), which dealt with Pakistan, and the South East Asian Regional Office (SEARO), which was charged with the task of working with the other subcontinental governments (including Bangladesh after 1971). An assessment of all such discussions, which is best done through a study of unpublished telegrams, letters and reports available in the various WHO archives, reveals that officials located within different levels and departments of the regional offices continued to hold disparate views right until global smallpox eradication was formally certified. 4 5

As is to be expected, the prevalence of numerous ideas about how work ought to be carried out within SEARO and EMRO influenced the many ways in which eradication policies were implemented. Like the WHO HQ in Geneva, the regional offices were not monolithic bodies. Some officials were more enthusiastic than others about the goal of variola eradication, and divergences in policy implementation were further encouraged by the fact that Regional Directors remained keen to advertise their autonomy by seeking to reconfigure guidelines received from the HQ, usually on the basis of their own understanding of local requirements. Such variation in bureaucratic support within the WHO was frequently identified in internal, unpublished documents as a significant impediment to the smooth running of the overall programme. This helps explain why SEARO structures were reorganised in the 1970s, clearly in an effort to ensure smoother and direct interactions between the Smallpox Eradication Unit headed by Donald Henderson in Geneva and the field officers in the region. Notably, this took the form of setting up a unit in New Delhi, within the SEARO establishment, which was put in Nicole Grasset’s charge; this body was made directly answerable to Henderson and his team and also given access to special funds donated by a variety of funding agencies (the Swedish International Development Agency was a major contributor towards the costs of the so-called intensified phase of activity in India and Bangladesh in the 1970s). The aim, it appears, was to counteract the then SEARO Regional Director’s opposition to the way the smallpox programme was being run in South Asia, and develop a relatively independent taskforce drawn from a variety of WHO-affiliated workers, both international and South Asian. 4

This reorganisation of personnel helped in other ways as well. For example, it allowed for the inflow of a miscellany of ideas from the field about how best to adapt to a variety of local conditions (this information was often forthcoming from South Asian field officials of different ranks, who were involved in great numbers on contracts of varying lengths). Placed in the hands of Geneva- and New Delhi-based managers who were willing to avoid the strict top-down imposition of centrally dictated policies, to negotiate with the target population and, not least, to adapt work to assuage local concerns and innovate in relation to the running of the so-called search and containment strategies that were central to the campaigns of the 1970s, such input was invaluable. Indeed, it allowed teams of international and local workers, who were generally mobilised in groups containing personnel of different nationalities (the Indian government insisted on such an arrangement before allowing foreign epidemiologists to work in the country), to respond quickly to a diversity of local crises and social, political and economic needs. 10 That the personnel were spared the need to get endless bureaucratic clearances for finances controlled by the Regional Director and national governments helped enormously, as it saved valuable time and allowed for greater flexibility. 4 9

This is not to say that opposition, from within WHO agencies and complex national political frameworks, disappeared completely over time. Indeed, pockets of often intense hostility remained in a situation where the Regional Directors retained powerful political alliances within and across national borders; this was compounded by the significant power held by critics within South Asian national, provincial and district governments and their various departments, and the doubts about the efficacy of vaccination harboured by some sections of society. 11 Strikingly, not all public health and medical officials were supportive of smallpox eradication, as many considered the goal an impossible one and, therefore, a misguided waste of scarce resources. Administrative bottlenecks frequently resulted, as plans suggested by the WHO’s smallpox eradication units in Geneva and New Delhi were questioned and, sometimes, blocked within different levels of South Asian administration. These trends threw up vital challenges in a situation where WHO officials had varying levels of access to different national territories; problems that, it has to be noted, could be overcome only through sustained negotiations with politicians and bureaucrats of all ranks (including members of the political opposition), and members of the target population. As mentioned earlier, international workers could not just fly into the national capitals and then disperse as they wished. In all cases, they required clearance from a country’s federal authority for entry and work, with additional paperwork required for visits to politically sensitive enclaves (India’s North Eastern Frontier Area, as it was then designated, was a case in point, as was the highly disturbed Indo-Bangladeshi border in the 1970s).

The result, therefore, was a complex patchwork of distinct plans and patterns of work in a multiplicity of urban and rural areas. These coexisted uneasily, and sometimes openly came into conflict owing to the influence of a variety of administrative, economic and social factors; situations that required careful resolution through sensitive diplomatic negotiations carried out by WHO workers in association with their allies in national and local government. Force was sometimes used to counter opposition to vaccinations associated with search and containment regimes, but these were exceptions rather than the norm. Once again, these initiatives could not be carried out by WHO personnel in isolation, as the danger of a violent social and political backlash was acute—unpublished WHO and government correspondence regarding campaigns of forcible immunisation suggests careful planning and synchronisation of efforts between organisational employees, South Asian politicians of all ranks and hues and, not least, national and local military, paramilitary and police forces (links that were almost universally downplayed, by all involved, once smallpox eradication had been achieved). It was a combination of all these initiatives that allowed for the eradication of smallpox in South Asia, which was crucial to the ultimate removal of the disease globally. 4 5 12

CONCLUDING COMMENTS

The global eradication of smallpox is, by any measure, an enormous achievement. To recognise that this goal was reached in the face of tremendous difficulties, often emanating from within the organisations involved in the planning and implementation of policies, does not detract from that accomplishment. However, it does serve as a reminder that scholars should avoid being swept away by the heroic narratives that tend to predominate in official histories prepared after the certification of eradication. Historians and other chroniclers need to be equally careful about being over-reliant on reports published during the programme’s earlier stages, as these tend to offer only the views of a few people, who hoped, usually in vain, that their recommendations would be implemented as policy in the field. Ground realities, as this article attempts to show, were always significantly more intricate. And this complexity can only really be revealed by a careful analysis of unpublished papers dealing with the day-to-day discussions about policy, which are useful precisely because they reveal the views and actions of the thousands of field managers and personnel who contributed to smallpox eradication; their ability to study and adapt to a plethora of local conditions was crucial to the ultimate result and, therefore, merits recognition.

Assessing the intellectual, political and social agendas of a handful of senior WHO officials is fine as long as we do not end up assuming that everyone else associated with it was devoid of both intellect and the ability to make a difference in the design and implementation of policy. The views of WHO Directors General, their advisors and overall heads of disease control programmes are undoubtedly important. Yet, it is important to remember that their views were neither static nor able to dictate the day-to-day running of a highly complex organisation. At the same time, it would be foolhardy for the historian seeking to study the complex interplay between global, regional, national and local forces to ignore the complicated political networks that different constituents of the WHO had to contend with on a daily basis, often through the offices of staff employed locally on a variety of short-term contracts. 13

The attempt here is to emphasise the difference between theory and practice; the need to distinguish between the official rhetoric from the WHO HQ and regional offices and the nature of work actually carried out in a variety of field situations is of paramount importance. This would allow the preparation of more rounded histories of health campaigns run on a global scale, which were—and continue to be—reliant on the assistance provided by numerous local political and social actors. And unlike some relatively thinly researched and jargon-filled analyses of the thoughts and actions of a few senior organisational personnel, 3 8 a thorough assessment of the intricacies of global health organisations and their links to national and local governments can actually provide useful insights into the management of current health programmes. Apart from anything else, the careful examination of policy implementation would suggest that the acute differences between vertical and horizontal health programmes, which analysts dependent on published policy assertions regularly allude to, 14 15 are far less marked than assumed. Indeed, local infrastructural exigencies and field experiences often forced developments that blurred the lines between preventive and curative medicine; an important point to remember when the WHO HQ’s renewed emphasis on the worldwide regeneration of the structures of primary healthcare is stoking interesting discussions, within and outside the organisation, about its ability to bring about meaningful changes in developing, less developed and developed countries.

What this study adds

A new historical perspective on the World Health Organization and its multifaceted involvement in the global smallpox eradication programme, which is one of the greatest medical achievements of the twentieth century.

Policy implications

This article suggests the adoption of historical methodology that can, the author feels, help prepare nuanced studies that can provide insights into ways of developing flexible and multifaceted international and global health campaigns.

Acknowledgments

I would like to thank the Medical Humanities Division of the Wellcome Trust, UK, for a project grant that made research for this article possible. I am grateful for fruitful discussions with Sangeeta Chawla, Paul Greenough, Niels Brimnes, Gilberto Hochman, Anne-Marie Moulin, Guy Attewell, Liew Kai Khiun and Rohan Deb Roy. However, I remain responsible for any mistakes.

Funding: Research for this article has been funded by the Medical Humanities Division of the Wellcome Trust, UK.

Competing interests: None.

Elon Musk, NPR, and a Signal smear campaign

In the year of our Lord 2024, is there any topic at all that can’t become fodder for the culture wars? Apparently not. Case in point: The dumb-as-hell fracas that’s broken out on X about the cryptographic integrity of two messaging apps, Telegram and Signal . The debate boils down to which app’s technical standards are more likely to protect user privacy—a topic you would think is an empirical one to be decided by math nerds. Alas, this simple but important issue has, like a bystander caught by a stray bullet, been dragged into a larger culture war fight between Elon Musk, the public broadcaster NPR, and each side’s respective groupies.

The messaging app turned culture war debate has been raging for a while now in niche circles (I tweeted about it a week ago in the context of crypto), but got pushed into the mainstream when the Guardian published a closer look at the forces driving it. In an essay published this weekend, a Stanford researcher describes how, after a longtime editor decided to rage quit over NPR’s left-wing politics, conservatives began gunning for the broadcaster’s CEO. In the ensuing fight, some loudmouth discovered that the CEO sat on the board of the Signal Foundation, and began making insinuations that Signal was somehow compromised because of this. And Musk, being who he is, piled on and began hinting without any evidence that a conspiracy was afoot.

If you’re wondering, my own politics are centrist. I find there is excellent reporting—and plenty of bias and bad stuff, too—to be found in publications across the political spectrum. (And as someone who toils in media, I’ll add I get frustrated with the left’s refusal to acknowledge its own bias. While someone at Fox News is likely to say “Yeah, we’re right wing—so what?” the liberal high priests at the New York Times or Columbia Journalism School will tell you, “We don’t have an agenda. We perform JOURNALISM.”) But that’s getting beyond the topic at hand, which is whether the NPR president’s slight involvement with Signal should lead us to distrust the app. The short answer is: That’s ridiculous.

Whether or not an NPR person is on its board, Signal is open-source and encrypted, which is what you want if you care about security. Meanwhile, the consensus among cryptographers I’ve met—who don’t strike me as raging leftists—is that Signal’s tech is first-rate. It also doesn’t hurt that the app was built by an American who is a hard-core privacy fanatic. Contrast that with Telegram, which lacks end-to-end encryption (even Mark Zuckerberg’s WhatsApp has this!) and is broadly suspected of being back-doored by the Kremlin. For me, this is an easy decision that has nothing to do with culture war stuff and everything to do with technology. Signal is the one I trust for privacy but, as they say, you do you.

An earlier version of this newsletter incorrectly stated Telegram has servers in Russia.

Jeff John Roberts [email protected] @jeffjohnroberts

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Chinese, Iranian, and Russian gangs are attacking U.S. drinking water and officials are alarmed

Amazon CEO Andy Jassy: An ‘embarrassing’ amount of your success in your 20s depends on your attitude

The starting salary for a new American Airlines flight attendant is low enough to qualify for food stamps in some states

Red Lobster is blaming its bankruptcy on top shareholder and its ex-CEO, saying an $11M all-you-can-eat-shrimp fiasco contributed to its demise

Peloton, the fallen fitness unicorn, faces a harsh truth despite its shiny new deal with Hyatt hotels: ‘I don’t think they thought [about] what was going to happen post-pandemic’