Iris Borowy, Institut für Geschichte, Rheinisch-Westfälische Technische Hochschule Aachen
Ever since the term “global health” entered the vocabulary of the international health discourse it has aroused discussions about what it means, how it came about, what has contributed to the new concept and to what extent it is new or, on the contrary, little more than old wine in new bottles. Apparently, its roots in colonial and post-colonial medicine mix with a humanitarian rationale and wider globalized tendencies, whose effects of strengthening democracy and empowerment coexist uneasily with the increasing inequities of a neoliberal global world order. Strangely enough, though a recent Global Health & Science and Technology Studies workshop in Maastricht addressed similar questions in a STS context, historians have so far paid little attention to the role played by academia in this field. This is surprising since universities, research institutions and individual scientists have undoubtedly had a major impact on how medicine, health care and health itself have been developed, (re-)constructed and delivered worldwide. After all, global health work evolved within a larger context of Northern efforts to promote the “development” of Southern countries, and universities, and research institutions figured prominently among the places where doctors and other health workers were trained before engaging in medical “development” work, and they were often places where projects to address public health and medical care in Southern countries were designed.
The workshop organized on 21/22 November 2013 at the Institute for the History, Theory and Ethics of Medicine of the RWTH Aachen University within a new research project on the history of German international health work, headed by Walter Bruchhausen, sought to provide a first step to explore the involvement of Northern universities and academic research within the broad range of international activities aiming at the improvement of health in Southern countries between the Second World War and the present.
In his introduction WALTER BRUCHHAUSEN pointed out that the response to the call for papers had reflected this ambivalent state of the question in present historical scholarship: lively interest had contrasted with a tangible scarcity of ongoing studies. This apparent neglect could be traced to the complex nature of international health at universities, characterized by a lack of commitment from the institutions, of central archives (in contrast to government and church organizations) and of clear policies. Thus, evading easy investigation, the example of Germany showed how academic international health had been subjected to changing intellectual, ideological and political influences.
The first session addressed two case studies, presented by LAUREN HUTCHINSON (London) and LUKAS MEIER (Basel), which introduced pertinent questions regarding motivations, purposes and responsibilities of medical research. In the 1960s, a research project addressed the long-term effects of large-scale irrigation on arbovirus morbidity in the Kano Plain in Kenya. The project was negotiated with the Kenyan government but designed and implemented by the British Medical Research Council (MRC). Its rationale turned out to be questionable when it became clear that the arbovirus was harmless to humans and that irrigation was never used to any great extent in the vicinity of the project. While this initiative clearly followed a line of post-colonial relations with a region in which British influence had been and should continue to be strong, institutions in Switzerland had no such tradition to tap into. Thus, the Swiss Tropical Institute (STI) introduced health as a focus area in which to become an actor in the emerging scene of international “development” work. In the process, both Swiss foreign policy and research gained international stature. This outcome provoked questions in the audience about responsible decision makers, about possible (neo-)imperialist structures but also about the evaluation of a project result which was worthless for the local population but scientifically interesting.
The political repercussions of a Northern initiative implemented in a Southern country featured prominently in a paper by MESELE TERECHA KEBEDE (Oslo). The Norwegian and Swedish Save the Children Federations financed the building and early management of the Armauer Hansen Research Institute in Ethiopia, combining a humanitarian impulse with the aim to retain intellectual ownership over a disease where Scandinavia had claimed scientific pre-eminence since Hansen had identified the causative pathogen of leprosy in the nineteenth century. Meanwhile, the Ethiopian government under Haile Selassie incorporated the institute in his plans towards “hygienic nation-state formation.” Interestingly, the institute survived and reconstructed its mission after both motivations disappeared when a military dictatorship took power in 1974 and the Scandinavian organizations pulled out of the project some years later.
In a session with a focus on Germany, papers by MARION HULVERSCHEIDT (Kassel) and IRIS BOROWY (Aachen) juxtaposed two approaches from West and East Germany. Throughout the twentieth century, the Bernhard-Nocht-Institute of Tropical Medicine in Hamburg offered courses in tropical medicine. From the 1960s onwards, these courses were presented in terms of “development” aid though they remained firmly committed to a narrow view of health work as a vertical fight against individual diseases, increasingly at odds with its rhetoric. Similarly, East German efforts in the international health field of academia were motivated by foreign policy and economic goals despite a different public rhetoric of solidarity. Thus, the activities of scholars and institutions represented one instrument among others to gain international recognition in the face of West German hostility, and to find foreign markets for pharmaceutical products. These findings triggered comparisons to experience in other countries, notably Cuba, and to ways in which health work routinely formed part of national foreign policy.
On a different note, LYDIE CABANE (Bordeaux) explored the rise of the expression of “global health” since the late 1990s, tracing its connection to a substantial increase in its use in academic publications in North American universities, notably Harvard. Harvard-based academics like Paul Farmer, Julio Frenk, Jeffrey Sachs and Jim Yong Kim played key roles in communicating this new conceptualization to international organizations like the WHO and the World Bank. Discussions raised the question to what extent it could be unequivocally clarified whether the expression had spread from academic publications to politics and international organizations or vice versa.
The second day shifted the discussion from “development aid” and primarily Northern initiatives to the countries without a recent colonial past in Latin America. MARIAN ARAUJO YASELLI (Alicante) analysed how successive governments of Venezuela welcomed or actively invited foreign medical experts. This form of knowledge transfer was facilitated, on the one hand, by the activities of the Rockefeller Foundation in the medical field, which facilitated the movement of American health experts, and, on the other hand, by the rise of fascism in Spain and Germany, which prompted doctors from these countries to emigrate and seek new places of work. The lively discussion questioned to what extent academics from different countries brought different concepts of medical and health work or to what extent they shared similar ideas because of a common experience of Rockefeller fellowships even before emigration. Similarly, it was argued whether ideological differences, notably between German doctors fleeing Nazism before the war and denazification after the war, were superseded by a common situation of having to re-invent their lives as immigrants.
The following papers similarly addressed questions of agency and of the origin of “ownership” of knowledge within a context of international organizations. CHRISTIANE BERTH (Basel) analysed the work of the Institute of Nutrition of Central America and Panama (INCAP), whose long-time director as well as numerous consultants came from North American universities. Dedicated to doing research on and finding practical solutions for nutrition problems in Central America, INCAP adopted a technical approach to nutritional deficiencies by inventing high-protein food supplements. However, instead of transferring Northern health models to Central America the agency aimed at developing and promoting local solutions, adapted to local circumstances. Subsequent discussions questioned to what extent local knowledge could be reconciled with the focus on laboratory-based solutions at the expense of agricultural expertise.
In his paper on smoking as a social habit in Argentina, DIEGO ARMUS (Swarthmore College) traced how the image of the smoker had undergone profound changes in recent years. After decades of unsuccessful efforts by fringe anti-smoking groups, large-scale anti-tobacco campaigns of the WHO and the Bloomberg Foundation, informed by research in Northern academic institutes on the health repercussions of smoking shifted the connotations of smoking from an image of fun and rugged independence to that of inconsiderate behaviour and a public nuisance. The workshop participants disagreed on the extent to which smoking regulations represented sensible health policies or intrusive regulations of personal lives.
WOLFGANG BICHMANN and EKKEHARD SCHRÖDER (Frankfurt am Main / Berlin) offered an eye witness perspective on the training courses for „medical development workers“ at Heidelberg university during the 1970s and 1980s. In an approach which sought to distance itself from the biomedical focus in Hamburg, these courses combined a three-week class on tropical diseases in Hamburg or Tübingen with four weeks of teaching in primary health care, medical practice in “developing countries” and medical anthropology. Subsequent discussions focused on the question to what extent this approach reflected earlier and later concepts of social medicine and social determinants of health or whether both institutes shared a similarly medicalized approach to public health.
As a final contribution, ALEXANDER MEDCALF (York) reported on a project, organized jointly by the York Centre for Global Health Histories and the WHO. This program offers lunch seminars at the WHO in Geneva, each dedicated to a specific topic on which a specialist historian and a specialist current health worker offer presentations. The initiative seeks to integrate historical perspectives into ongoing considerations of health themes, and it appears to be successful to the degree that a recent WHO World Health Report included a reference to it. While the overall response of workshop participants was most positive to a program which turned historians of health into objects of the workshop theme, there were questions about the degree to which it reflected an anglicized perspective on world health. Generally, it was appreciated that any program involving a very small group of decision makers would face difficulties of creating a balanced selection of topics and presenters. No consensus was reached on the question of whether historians could or should have an active impact on ongoing health policies.
Generally, all participants agreed that it had been a very fruitful meeting which raised a number of questions for possible subsequent work. Thus, in view of the multitude of actors and the fact that many of them moved in between regions and institutions the original perspective of Northern academia and Southern recipient countries appeared simplistic. In addition, the paths of traveling academic knowledge and its hybridization clearly deserved further study.
Walter Bruchhausen (RWTH Aachen): “Chronologies, Nationalities and Disciplines in Academic International Health: An Introduction”
Medical Development Cooperation: UK and Switzerland
Lauren Hutchinson (London School of Hygiene and Tropical Medicine): “Following a Post-Colonial Biomedical Collaboration between the UK and Kenya 1968–76“
Lukas Meier (University of Basel): “Health for the people. The Emergence, Rise and Persistence of “Health” as a Focus Area of Swiss Development Aid and the Role of the Swiss Tropical institute (STI), 1960–1970”
Research in International Health: East and West Germany
Marione Hulverscheidt (University of Kassel): “The Research Program Regarding ‘Medical Development Aid’ of the Bernhard Nocht Institute for Tropical Diseases, Hamburg/Germany”
Iris Borowy (RWTH Aachen): “Medicine, Economics and Foreign Policy: East German Scientist-Doctors in Low-Income Countries in the 1950s and 1960s”
Research Institutions: North and South
Mesele Terecha (University of Oslo): “The Armauer Hansen Research Institute in Ethiopia: A History, 1969–2004”
Lydie Cabane (University of Bordeaux): “Going Global. The Making of Global Health Academic Programs in Northern Universities”
Developing Public Health in Latin America
Marian Araujo Yaselli (University of Alicante): “Public Health in Diagnosis: Analysis of the Venezuelan Health and Social Welfare Ministry (1936–1952)”
Christiane Berth (University of St. Gallen): “Between Local Solutions and External Dependencies: Knowledge Transfers at the Institute of Nutrition of Central America and Panama (INCAP), 1949–1980”
Diego Armus (Swarthmore College): “Global and Local Actors in the Remaking of Anti-Smoking Campaigns in Buenos Aires”
The German University at International Health: Eye Witness Perspective
Wolfgang Bichmann / Ekkehard Schröder
(Frankfurt and Berlin): “From Training Medical development workers to medical anthropologically-based inter¬national community health – the 1970ies and 1980ies at Heidelberg University”
International Health: Developing Historiography
Alexander Medcalf (University of York): “History’s Contribution to Global Health”