Portal de Periódicos da CAPES

The Rockefeller Foundation and the international health agenda

2013; Elsevier BV; Volume: 381; Issue: 9878 Linguagem: Inglês

10.1016/s0140-6736(13)61013-2

1474-547X

Anne‐Emanuelle Birn, Elizabeth Fee,

Global Health and Surgery

Although no longer the only philanthropic institution equated with global health, the Rockefeller Foundation (RF) has marked the field like no other organisation. Incorporated a century ago this month, the RF established health cooperation as a legitimate intergovernmental and private agency endeavour, and shaped the principles, practices, and key institutions of the international health field. Unlike media-savvy global health actors today, the RF did not flaunt its role but often remained behind the scenes: we might liken its pervasive influence to its eponymous founder's own work style, as observed by his longtime secretary in 1925: "He's never there, and yet he's always there". The RF was established in 1913 by Standard Oil magnate John D Rockefeller "to promote the well-being of mankind throughout the world". His efforts were part of a new American movement of "scientific philanthropy", launched by Scottish-born steel mogul Andrew Carnegie in his 1889 essay "The Gospel of Wealth". This approach called for the wealthy to channel their riches to the good of society by replacing individual charity with support for systematic social improvement, which was conducive to order, productivity, and secular advancement. In the tumultuous Progressive Era of the early 20th century, many contemporaries regarded philanthropy as a cynical use of exploitation-derived profits to counter the threat of working class unrest and growing political radicalism. These philanthropic efforts helped stave off the welfare state in the USA and gave private interests considerable purview over social welfare. Rockefeller built upon Carnegie's ideas, expanding from initial hospital, church, and university donations to cover public education, medical, and scientific spheres. Public health became the ideal vehicle through which Rockefeller philanthropy could apply scientific findings to the public good. Rockefeller's business, scientific, and philanthropic advisers Frederick T Gates, Charles Wardell Stiles, and Wickliffe Rose perceived anaemia-provoking hookworm disease to be both a key factor that explained the economic "backwardness" of the USA's southern states and an impediment to its industrialisation. These men helped orchestrate the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease that operated from 1910 to 1914. This campaign uncovered the possibilities of public health in eliminating the disease through an anthelmintic drug; the promotion of shoe-wearing and latrines; and public health propaganda. Following this success, the RF created an International Health Board, which was reorganised as the International Health Division (IHD) in 1927. The IHD—which had a sizeable bureaucracy including an executive staff and advisory board in New York, as well as field offices in Paris, New Delhi, Colombia, and Mexico, and hundreds of in-country officers—befriended dozens of governments around the world by tackling diseases deemed to cause underdevelopment, helping build and modernise health institutions, promoting the importance of public health among countless populations, and preparing vast regions for investment and increased productivity. It also funded schools of public health in North America, Europe, Asia, and South America, including at Johns Hopkins, Harvard, Toronto, and São Paulo universities, and the London School of Hygiene and Tropical Medicine, and sponsored 2500 public health professionals to pursue graduate study. By the time of its dismantling in 1951, the IHD had spent the current-day equivalent of billions of dollars on scores of hookworm, yellow fever, and malaria campaigns, as well as on more delimited efforts against tuberculosis, yaws, influenza, rabies, schistosomiasis, malnutrition, and other health problems in some 93 countries and colonies. RF disease campaigns tended to be run with business-like efficiency: specific interventions were planned with measurable goals and results regularly reported to the central office, serving to hold field officers accountable as well as to quantify progress in quarterly reports reviewed by trustees, who were leading men from the worlds of medicine, education, and banking. The RF's genius rested in its ability to turn disease campaigns into permanent public health agencies supported by local constituencies. With its own field officers stationed in virtually every setting where it operated, it could rely on a well-honed staff to infuse—often in the face of resistance and refashioning—its particular ideas and approaches into local efforts to institutionalise public health. To be sure, the RF was a complex institution that changed over time, responding at different moments to certain senior staff and board members, counterparts in the field, and a shifting political terrain. It also met with local and institutional adaptations and sometimes even embraced challenges to its efforts. It had powerful local interlocutors in the thousands of public health doctors, nurses, and engineers it trained as fellows: moulded as a cadre of public health leaders, fellows were encouraged to bypass local healers and knowledge and affiliate with international colleagues. The RF carefully avoided disease campaigns that might be costly, overly complex, time-consuming, or distracting to its technically oriented public health model and its focused means of measuring success. One of the most cited RF accomplishments was yellow fever control, which involved extensive campaigns across Latin America to reduce the presence of the Aedes aegypti mosquito vector through insecticide spraying, drainage, use of larvicidal fish, and the development of the Nobel prize-winning yellow fever vaccine in 1936. Ironically, this was far more a success for international commerce—given that the yellow fever virus was transported alongside cargo and was lethal mainly for those previously unexposed, not where the disease was endemic—than for local health. The IHD itself identified its most important contribution to be "aid to official public health organizations in the development of administrative measures suited to local customs, needs, traditions, and conditions". Thus, the RF's self-defined gauge of success was its role in generating political and popular support for public health worldwide, and advocating for and sustaining the institutionalisation of international health. The RF had a geopolitical role that went well beyond health, stimulating investment, development, and economic growth; stabilising colonies and emerging nation-states by helping them meet the social demands of their populations; improving diplomatic relations; expanding consumer markets; and encouraging the transfer and internationalisation of scientific and cultural values. At the same time as the RF was involved in country-by-country activities, it was also mapping international health's institutional framework. Its organisation and practices provided the groundwork for a new, legitimate international health architecture with its own bureaucracy and modus operandi. The League of Nations Health Organisation, founded after World War 1, was partially modelled on the RF's International Health Board and shared many of its values, experts, and know-how in disease control, institution-building, and educational and research work. When the League of Nations Health Organisation faced a financial crunch, the RF became its major patron, eventually funding much of its operating budget. After the establishment of WHO in 1948, the IHD was disbanded. Yet it maintained an indirect presence for decades: both the postwar Director of WHO's Americas office and the long-serving second WHO Director-General had been leading IHD men in Brazil. Even after the RF drew back from its frontline role in international health, it kept a hand in activities related to health and development—through funding the "Green Revolution" in agriculture, the Population Council, and social science and medical research. Starting in the late 1970s, it sought to circumscribe WHO's shift to primary health care to a more technical and less sociopolitical variant. During the 1980s, the RF established the International Clinical Epidemiology Network and the Great Neglected Diseases of Mankind Program. In the 1990s, it created Public Health Schools Without Walls; launched a Health Equity initiative; and largely invented the model of public-private partnerships that is now so omnipresent in global health. But the RF would not recover its earlier influential role in international health. The IHD's demise served as a self-fulfilling prophecy of success: thanks to its own efforts, it was no longer needed. But this was no death knell for Rockefeller international health. The principles that were pioneered by the RF and infused in the IHD's country dealings have left an enormous—if sometimes problematic—legacy for global health. These principles include agenda-setting from above; use of budget incentives; a technobiological paradigm; narrow interventions to maximise efficiency and success; consensus through transnational professionals; and adaptation to local conditions. While these are arguably generic principles, their durability reflects what Steven Palmer has called "marked asymmetries in political and medical power" that characterise most international health interactions, then and now. The RF also diverged at times from its own principles, funding studies of universal health insurance and supporting certain social medicine efforts that integrated the sociopolitical conditions underlying health with overall public health work. But these were accompaniments to, rather than at the core of, the RF approach to international health. The RF principles have continued ideological salience and bureaucratic convenience, as witnessed in the structure, strategies, and tenets of the global health field today. Today, of course, we cannot discuss health philanthropy without invoking the Bill and Melinda Gates Foundation, which has emulated the RF's technically oriented approach to health. Yet both foundations currently differ from the RF of yore. In the past, the RF championed public responsibility for public health and was open to wide-ranging discussions. More recently, the RF, having reinvigorated its global health role, has expressed support for universal health care coverage but only through "harnessing the resources of the private sector to finance and deliver health services". The RF also promotes "impact investing", inducing venture capitalists to "address social and/or environmental problems while also turning a profit". Perhaps the marking of the RF's centennial will stimulate internal reflection, inducing the foundation to return to its historic aims of broadly improving wellbeing, rather than generating profits for investors. Funding for A-EB's role in writing this paper was provided by the Canada Research Chairs Program. The funder had no other role in this paper, and the ideas expressed herein are the authors and not those of any institutions with which they are affiliated. Funding for A-EB's role in writing this paper was provided by the Canada Research Chairs Program. The funder had no other role in this paper, and the ideas expressed herein are the authors and not those of any institutions with which they are affiliated.