Influence and opportunity: reflections on the U.S. role in global public health

Today's global health crisis illustrates many of the transnational governance challenges the United States faces today. In the arena of global health, the United States can create a new role for itself by moving beyond a national-interest paradigm and strengthening its "soft power" position in health. Health in recent administrations has moved beyond being "just" a humanitarian issue to being one with major economic and security interests. Despite U.S. unilateralism, new approaches to global health governance are being developed by other actors, who have influenced the U.S. agenda and made important contributions. Yet a larger leader is still needed, especially in identifying and following a sound legal and regulatory global health governance system; bringing political legitimacy; and setting priorities. Responsible political action is needed to develop a new mindset and lay the groundwork for better global health in the future.     

A fundamental shift in the approach to international health by WHO, UNICEF, and the World Bank: instances of the practice of "intellectual fascism" and totalitarianism in some Asian countries.

Navarro has used the term "intellectual fascism" to depict the intellectual situation in the McCarthy era. Intellectual fascism is now more malignant in the poor countries of the world. The Indian Subcontinent, China, and some other Asian countries provide the context. The struggles of the working class culminated in the Alma-Ata Declaration of self-reliance in health by the peoples of the world. To protect their commercial and political interests, retribution from the rich countries was sharp and swift, they "invented" Selective Primary Health Care and used WHO, UNICEF, the World Bank, and other agencies to let loose on poor countries a barrage of "international initiatives" as global programs on immunization, AIDS, and tuberculosis. These programs were astonishingly defective in concept, design, and implementation. The agencies refused to take note of such criticisms when they were published by others. They have been fascistic, ahistorical, grossly unscientific, and Goebbelsian propagandists. The conscience keepers of public health have mostly kept quiet.     

中国全球健康相关非政府组织的发展策略浅析

国际非政府组织在全球健康治理中发挥了重要作用,也是各国发挥国际影响力的重要渠道,但中国非政府组织目前参与全球健康治理甚少。本文旨在分析中国非政府组织发展的社会政策环境、健康类非政府组织的发展现状并借鉴国外新兴的全球健康相关非政府组织的经验,为中国扶持非政府组织参与全球健康治理提供策略建议。本文发现,中国参与全球健康治理有较好国际机遇;国内社会组织发展环境趋势向好,但具有依附行政体系、政策定向发展等特点。因为专业性、公共服务属性以及与公共治理相关性小,非政府组织参与全球健康可以得到政府的全力支持。健康类非政府组织数量较少、基础较差、参与国际合作少。不同类型健康类社会组织各有长短,国际经验提示新兴机构主要依靠政府力量扶持非政府组织参与全球健康。建议我国政府采取"重点扶持,整体改善"的策略,制定中国全球健康发展战略,以政府附属与社会精英创办的大型非营利机构为重点扶持对象,引导和资助健康类非营利机构走向国际舞台。     

全球卫生治理机制及中国参与的建议

随着全球化的纵深发展,全球卫生逐渐取代国际卫生,成为学界关注热点.全球卫生领域存在诸多亟需解决的问题,而这些问题的解决需要良好的全球卫生治理,实现全球卫生治理的五大功能,即达成价值观念的共识、制定相应的规则、实现治理的多元化、动员和分配资金、提供领导和协调等.针对全球卫生领域的不同趋势,建议确立以世界卫生组织为中心的全球卫生治理体系、在世界卫生组织框架内实现治理的多元化以及加强全球卫生立法等.中国作为新兴经济力量,在全球卫生治理中占有重要地位,应更为活跃地参与全球卫生治理.首先,建议中国制定国家层面的全球卫生战略;其次,积极参与全球行动网络和治理平台;最后,培养全球卫生研究和实践人才.     

The evolution of human rights in World Health Organization policy and the future of human rights through global health governance

The World Health Organization (WHO) was intended to serve at the forefront of efforts to realize human rights to advance global health, and yet this promise of a rights-based approach to health has long been threatened by political constraints in international relations, organizational resistance to legal discourses, and medical ambivalence toward human rights. Through legal research on international treaty obligations, historical research in the WHO organizational archives, and interview research with global health stakeholders, this research examines WHO's contributions to (and, in many cases, negligence of) the rights-based approach to health. Based upon such research, this article analyzes the evolving role of WHO in the development and implementation of human rights for global health, reviews the current state of human rights leadership in the WHO Secretariat, and looks to future institutions to reclaim the mantle of human rights as a normative framework for global health governance.     

传染病问题的全球治理机制及其完善

为了应对新发传染病带来的全球卫生危机,国际社会发展和完善了现代国际卫生合作机制,初步形成了传染病的全球治理机制。由于受到全球经济发展不平衡、国际民主失衡与冲突频发、多个并存的国际组织公共卫生职能重叠、非政府组织参与全球卫生治理的有效性有待提高等因素的影响,初具雏形的传染病全球治理机制还比较粗糙,有待在传染病治理的实践中接受检验并不断完善。建议加强世界卫生组织的领导地位、增加全球卫生投入、改善全球经济治理机构、推动国际政治民主化、协调伙伴关系、明确非政府组织的法律地位、重视健康的决定因素。     

The United Nations High Level Meeting on the Prevention and Control of Noncommunicable Diseases: A Missed Opportunity?

The United Nations High Level Meeting on the Prevention and Control of Noncommunicable Diseases (September 19–20, 2011) provided an opportunity to recast the current global health agenda and offered a formidable platform to mobilize political will for concerted action.We argue that the opportunity was missed because the World Health Organization (WHO) neglected the politics of process that are key to mobilizing political support for global noncommunicable disease policies. Instead, it focused on the implementation process.The lessons to be drawn from the summit are critical because the WHO is the key agency that will be expected in the near future to steer further discussions and debate on the noncommunicable disease agenda.ON SEPTEMBER 19–20, 2011, heads of state, government officials, and representatives of nongovernmental organizations (NGOs) met in New York City at an unprecedented high-level summit convened by the United Nations (UN) to discuss a critical new global agenda. The primary goal of the summit was to mobilize commitment to confront the worldwide threat posed by four “globally relevant” noncommunicable diseases (NCDs)—cardiovascular disease, cancer, diabetes, and chronic respiratory disease—and their associated risk factors: tobacco use, unhealthy diet, insufficient physical activity, and harmful use of alcohol. Throughout 2012 and 2013, the World Health Organization (WHO) is leading a range of follow-up efforts to set global targets and an action plan for monitoring NCDs worldwide. In assessing the impact of the NCD Summit, it is critical to look ahead at its long-term implications. The summit represented significant opportunities and challenges that will cast a long shadow unless they are addressed in the upcoming months.The UN NCD Summit generated high expectations worldwide. Between November 2010 and April 2011, the WHO prepared for the summit by holding five regional consultations led by its regional offices representing Europe, the Americas, South East Asia, Western Pacific, and Africa. Along with the Russian Federation, it also organized the First Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control, held in Moscow in April 2011. The summit was only the second time that the UN General Assembly, representing all 193 member states, met to discuss a global health agenda. In 2001, the UN General Assembly Special Session on AIDS resulted in a declaration of commitment on HIV/AIDS.The outcomes of the NCD Summit were disappointing. Although they yielded a commitment from UN member states to develop frameworks for monitoring NCDs and to identify indicators to assess national and regional strategies by the end of 2012 (Resolution 66/2), the summit did not lay down specific policy commitments for concerted action. International NCD coalitions and experts pressed for time-bound targets to make nations accountable, such as a 2040 goal for a tobacco-free world at a global commitment of $9 million and norms relating to taxation and industry regulation; these, however, proved elusive.1,2The WHO’s political leadership of the summit neglected the complexities of the NCD agenda and the challenges in building political will for its endorsement at the UN Summit. The high-level meeting also demonstrated that the WHO lacks a clear framework or approach to NCDs. Yet the setback holds important lessons for the WHO in particular—the lead specialized agency for NCDs within the UN—and for the NCD agenda worldwide. To move forward, however, we must look at the politics of the process leading up to the summit itself.The scale and scope of the problem of NCDs is tremendous. The UN secretary-general, in his opening address to the summit, delivered a “grim prognosis,” stating that NCDs represented a threat not only to health but also to global development and poverty eradication. NCDs are no longer perceived to be restricted to affluent societies. Of the 57 million global deaths due to NCDs, including 9.1 million before the age of 60 years, nearly 80% occurred in low- and middle-income countries. The world’s epidemiological and development profiles are now interlinked and complex.Against this urgent background, why did the UN Summit fail to make strong commitments to targets that had been hoped for? The political negotiations in the weeks preceding the meeting foretold its ultimate fate. On August 16, 2011, three presidents of the founding NGOs of the NCD Alliance (a formal collaborative of four international federations representing cardiovascular disease, diabetes, cancer, and chronic respiratory disease) wrote a letter to UN Secretary-General Ban-Ki Moon that criticized political stalling on the NCD agenda. They chided that “sound proposals for the draft Declaration to include time-bound commitments and targets are being systematically deleted, diluted and downgraded.” They stressed the need to mobilize greater “political will” from heads of states to commit to targets and concrete steps toward NCD prevention and control. The failure to mobilize political will, in large part due to neglect of the politics of process among key member states and other UN agencies, demands careful scrutiny.The impetus to hold the NCD Summit came from the Caribbean Common Market Countries in 2007; subsequently, however, strong advocacy led by key UN member states has been lacking. The WHO focused on mobilizing regional declarations of faith to the NCD Summit in the months preceding the meeting, but national-level mobilization was neglected. This oversight had significant fallout when individual member states, acting on the basis of national priorities, supported or rejected proposed targets at the summit. The resulting trends and alignments are neither new nor unfamiliar to the WHO. Since 2003, the WHO’s successes with NCD-related mobilization, such as in the arena of the Framework Control on Tobacco Control (FCTC), have been regarded as landmarks in mobilizing global support for a new public health agenda.However, commitments from countries such as China have recently slowed, as is evident from China’s delay in following up on its commitments to the FCTC. Other emerging economies such as Brazil and India who no longer qualify for international development aid and are unlikely to benefit from the promise of resources, have also been less energetic in promoting a global agenda for NCDs. European nations, the United States, and Canada are also reluctant to flag NCDs as a development challenge because this would probably divert the limited resources available for Millennium Development Goals—maternal and child health and communicable diseases, which are areas of historic concern to developed nations.There were also early signs that the WHO lacked a clear roadmap for building political support through institutional means. A complex issue such as NCDs requires a harmonizing of interests even within the UN itself so that a partnership-centered vision can be presented at the summit and to member states. However, there was no obvious approach to build a unified vision within and among UN agencies and to plan concerted action. The WHO’s past experience in forging decentralized and intersectoral alliances to build political support and resources for a new global health agenda has also been limited. For instance, the WHO leadership in the initial UN-led campaign against AIDS lacked the breadth and flexibility to initiate an intersectoral and cosponsored approach that was later pioneered by the Joint United Nations Program on HIV/AIDS (UNAIDS, launched in 1996).3,4In view of the WHO’s past challenges, what were the options for other players to shape and support its mandate at the NCD Summit? Over the past decades, international NGO networks have acted as brokers of knowledge and policy across the traditional divides in international relations between developed and developing countries. In the case of the UN NCD Summit, NGO networks also failed to mobilize political will. NGO networks that have played a significant role in mobilizing political support are relatively recent (e.g., the NCD Alliance, founded in May 2009), and their leverage, not surprisingly, has been limited. They have also lacked partnerships outside the health sector (e.g., NGOs working in the spheres of food, transport, or environment) that would be critical for building support for the NCD agenda and its risk factors.The leadership of the WHO, then, became the linchpin in determining the success of this summit. However, if we draw the right lessons from the summit, it can still be viewed as a watershed moment. In terms of mobilizing actions, the WHO needed to build national-level political commitment among member states prior to the summit and adopt a wider partnership-focused approach involving other UN agencies and funds. It also needed to ensure advocacy among national policymakers by international NGO networks that represent not only NCDs but also other intersecting sectors. Although it largely failed to develop these important preparatory activities, it is possible that effective follow-up work can help to overcome existing obstacles. For example, a meeting of the UN Funds and Agencies on the Implementation of the Political Declaration was held later, on December 8, 2011, marking the beginning of the potentially important process of making NCDs eligible for funding.5The summit also represented a significant beginning because it prioritized NCDs on the global agenda. It identified the broadest interpretation of their risk factors by relating them to causes that originate in structural determinants—environmental, social, political, and behavioral factors—such as poverty, lack of education, and gender that increase vulnerability to NCDs and exacerbate challenges to development. The summit also prioritized a multilevel process and intersectoral responses to meet the challenge posed by NCDs, and endorsed the WHO’s key role in the process ahead: to provide leadership and the evidence basis for international action.In view of this mandate, the most significant challenge for the WHO rests in mobilizing cross-cutting political support among a range of partners, and recognizing the critical role of the politics of process and consensus building with key political and social actors. Consensus building is complementary to—and should be pursued along with—the process of building evidence, setting targets, and implementation.Over the coming months, the WHO will need to work intensively at the national level through its country offices, with a bottom-up approach that aims to actively reshape national level perspectives toward NCDs. In particular, it will need to communicate to national-level policymakers that, rather than seeing the NCD agenda as replacing an older continuum of UN approaches relating to the eradication of infectious diseases, they need to view it as representing a paradigm shift in public health policies. In developing countries where populations face a growing dual burden of disease, the WHO can build policy support for NCD prioritization by advocating comprehensive approaches. It may also be important to begin to rethink the sharp distinction that has been made between communicable and chronic disease. This distinction, like that between primary and secondary care, has already begun to be questioned in some forums, as was evident in the meeting of the International AIDS Society, in Rome in 2011, which suggested that HIV and NCDs should be seen as sharing common needs and interests. The WHO will need to reinforce and build on these views and approaches to build national-level commitment to NCDs and to integrate them within preexisting health priorities.The next steps are for the WHO to work through multiple partners, such as other specialized UN agencies and international NGOs, to persuade states that their own proximate, national interests are at stake in what might otherwise be perceived as a remote, “global” problem. The WHO will also have to build cross-cutting alliances with the private sector, which holds the potential to collaborate and act with responsibility and ingenuity but also has ominously deep-rooted stakes in maintaining the status quo. A key element is preparing for the political process and building commitment among member states, donors, and other UN partners. Plans for implementation and meeting global targets will rest on member states. The continued development of this political process will ultimately determine whether or not the global NCD Summit was a missed opportunity or a landmark event marking the beginning of an important new era in the politics of global health.     

Long-term health implications of the Chernobyl accident and relevant projects of the World Health Organization

The past two decades have witnessed dramatic changes in public health governance and international cooperation on the Chernobyl Nuclear Power Plant accident, especially after the end of the Cold War. The World Health Organization (WHO) has committed itself deeply to the public health issues around Chernobyl and has participated in various health projects such as health monitoring and cancer screening. WHO has also been engaged in research activities such as the Chernobyl Tissue Bank, in close collaboration with the Ministries of Health in Belarus, Russia, and Ukraine. In addition to the official report of the Chernobyl Forum "Health Expert Groups" in 2005, the task of WHO is to not only analyze and clarify the global burden of Chernobyl-related illness, but also to promote the well-being of the local residents who suffered chronic low-level radiation exposure from radiation fallout.     

The health of peoples: predicaments facing a reasoned utopia.

How might nations cooperate to improve the health of their most vulnerable peoples? There is, presently, no coherent political, social, or ethical framework to answer this question. What progress there is remains piecemeal. Despite a long-term strategy to 2015 enshrining health as part of the process of human development--the Millennium Development Goals--existing institutions are struggling to meet these challenges. The WHO is underfunded and its work in countries is weak. The World Bank is rich but remains unable to free itself from a neoliberal Washington consensus. New institutions--such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria--distort efforts to build a coordinated international strategy for global health. And major policy initiatives (e.g., the Commission on Macroeconomics and Health) lack political commitment to invest in health. In this article, the author traces the beginnings of an answer to the question of what might constitute a political (specifically, foreign policy) approach to improving the health of peoples. A normative model for defining a just health system is urgently required. The author uses the framework of international relations provided by John Rawls to devise a series of policy principles for the health of peoples.     

The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals

The World Health Organization (WHO) continues to experience immense financial stress. The precarious financial situation of the WHO has given rise to extensive dialogue and debate. This dialogue has generated diverse technical proposals to remedy the financial woes of the WHO and is intimately tied to existential questions about the future of the WHO in global health governance. In this paper, we review, categorize, and synthesize the proposals for financial reform of the WHO. It appears that less contentious issues, such as convening financing dialogue and establishing a health emergency programme, received consensus from member states. However, member states are reluctant to increase the assessed annual contributions to the WHO, which weakens the prospect for greater autonomy for the organisation. The WHO remains largely supported by earmarked voluntary contributions from states and non-state actors. We argue that while financial reform requires institutional changes to enhance transparency, accountability and efficiency, it is also deeply tied to the political economy of state sovereignty and ideas about the leadership role of the WHO in a crowded global health governance context.     

Democratizing the World Health Organization

A progressive erosion of the democratic space appears as one of the emerging challenges in global health today. Such delimitation of the political interplay has a particularly evident impact on the unique public interest function of the World Health Organization (WHO). This paper aims to identify some obstacles for a truly democratic functioning of the UN specialized agency for health. The development of civil society's engagement with the WHO, including in the current reform proposals, is described. The paper also analyses how today's financing of the WHO – primarily through multi-bi financing mechanisms – risks to choke the agency's role in global health. Democratizing the public debate on global health, and therefore the role of the WHO, requires a debate on its future role and engagement at the country level. This desirable process can only be linked to national debates on public health, and the re-definition of health as a primary political and societal concern.     

WHO's Framework Convention on Tobacco Control potential impact on tobacco control in Japan

OBJECTIVE: The objective of the paper are to introduce the current global tobacco control measures undertaken by WHO and other international organizations, and to describe the impact on domestic tobacco control in Japan. METHODS: Publications and documents, mainly for WHO, were reviewed especially with reference to the Framework Convention on Tobacco Control (FCTC). RESULTS: WHO has been promotion comprehensive tobacco control globally as well as regionally in order to assist and promote its national health policy. In 1998, WHO established the Tobacco Free Initiative (TFI) to take action against the growing health impact of tobacco consumption around the world. WHO has also been proposing the FCTC, the first international convention in the health field, which includes, for example, restrictions on advertisement, selling to, or buying from persons aged under 18. Currently, the FCTC is being negotiated by governments and is expected to be ratified before May 2003. WHO is also working together with other international organizations, such as the World Bank, in synchronizing its global tobacco control policy. DISCUSSION AND CONCLUSIONS: "Smoking and health" is, without doubt, the most significant public health problem internationally and domestically. However, tobacco control tends to be less strict in Japan than in other developed countries. Even among health personnel in Japan, the health impact is still underestimated, thus its control remains partial. Accelerated public health campaigns against tobacco and health promotion activities are greatly needed. These could be carried out more effectively in the broad context of promotion of the FCTC.     

"The worst of both worlds": the management reform of the World Health Organization.

The governance and management of global health institutions, such as the World Health Organization (WHO), are under increasing critical scrutiny. This management case study explores the first year of transformation at the WHO under Director-General Dr. Gro Harlem Brundtland, focusing on the key stakeholders and the role of complexity in institutional change. This is a story about transition in a difficult, politically fraught, and management-resource-constrained environment. In the search for appropriate management paradigms, organizations such as the WHO may believe that the answers lie in harsh reengineering and the search for high-profile "success stories." Ironically, global business has moved away from such approaches and is far more focused on collaboration, empowerment, and knowledge sharing.     

Exploring the international arena of global public health surveillance

Threats posed by new, emerging or re-emerging communicable diseases are taking a global dimension, to which the World Health Organization (WHO) Secretariat has been responding with determination since 1995. Key to the global strategy for tackling epidemics across borders is the concept of global public health surveillance, which has been expanded and formalized by WHO and its technical partners through a number of recently developed instruments and initiatives. The adoption by the 58th World Health Assembly of the revised (2005) International Health Regulations provides the legal framework for mandating countries to link and coordinate their action through a universal network of surveillance networks. While novel environmental threats and outbreak-prone diseases have been increasingly identified during the past three decades, new processes of influence have appeared more recently, driven by the real or perceived threats of bio-terrorism and disruption of the global economy. Accordingly, the global surveillance agenda is being endorsed, and to some extent seized upon by new actors representing security and economic interests. This paper explores external factors influencing political commitment to comply with international health regulations and it illustrates adverse effects generated by: perceived threats to sovereignty, blurred international health agendas, lack of internationally recognized codes of conduct for outbreak investigations, and erosion of the impartiality and independence of international agencies. A companion paper (published in this issue) addresses the intrinsic difficulties that health systems of low-income countries are facing when submitted to the ever-increasing pressure to upgrade their public health surveillance capacity.     

The development of international health policies--accountability intact?

International health governance as it exists today is facing major structural challenges in view of globalization, the increased transfer of international health risks and the mounting challenge of health inequalities worldwide. As a consequence the capacity of nation states to ensure population health and to address major health determinants has been weakened. This paper explores health as an exemplary field to illustrate that we have entered a new era of public policy which is defined by increasing overlaps between domestic and foreign policy, multilateral and bilateral strategies and national and international interest. Cross border spill overs and externalities of national actions need to move into the core of public policy at the national and global level within a new rules based system. A new perspective on global health governance is further necessitated through the increased number of players in the global health arena. The organizational form that is emerging is based on networks and is characterized by shifting alliances and blurred lines of responsibility. The paper explores the emerging paradox of state sovereignty and makes a set of proposals to pool state sovereignty on health and structure the myriad of networks. Particular attention is given to the role of the World Health Organization within this process of change and adjustment. In using a framework from international relations analysis the paper explores how nation states are socialized into accepting new norms, values and perceptions of interest with regard to national and international health and what challenges emerge for the WHO in "inventing" global health policy.     

The stages of international (global) health: Histories of success or successes of history?

Abstract

International1 1. This paper uses the terms international health and global health according to general usage in the historical period under discussion. The term international health was likely coined in the early 20th century, emerging as the international sanitary conventions of the previous five decades gave way to permanent bodies addressing health concerns internationally. It was employed most prominently by the Rockefeller Foundation's International Health Commission (later Board and Division) launched in 1913. By the end of World War II, international health was in widespread use, but the new World Health Organisation (as a semi-independent specialised United Nations agency) crafted its own name around the unifying notion of ‘world health’. Still, the term international health retained its primacy. During the Cold War, the field of international health came to encompass the problems of health in underdeveloped countries and the efforts by industrialised countries and international agencies to address these problems. Global health – adopted broadly over the past decade – is meant to transcend past ideological uses of international health (as a ‘handmaiden’ of colonialism or a pawn of Cold War political rivalries) to imply a shared global susceptibility to, experience of, and responsibility for health. In its more collective guise, global health refers to health and disease patterns in terms of the interaction of global, national, and local forces, processes, and conditions in political, economic, social and epidemiologic domains. However, as Ilona Kickbusch (2002 Kickbusch, I. 2002. Influence and opportunity: reflections on the US role in global public health. Health Affairs, 21: 131–141. [Crossref], [Web of Science ®] , [Google Scholar]) has argued, this ‘new’ global health has also been used to assert US ‘global unilateralism’ that is, a tailoring of the world's health agenda to meet hegemonic US national interests and undercut bona fide internationalist efforts. Notwithstanding the invoked distinctions, there is considerable conflation between international health and global health, and the ‘new’ definition of global health bears many similarities to early 20th century understandings of international health. health funders, leaders and researchers frequently cite ‘successes’ in this field as validation for past labours and justification for future endeavours. However, the question of what constitutes success – from both historical and contemporary perspectives – has been inadequately analysed. This paper reviews and periodises understandings of success in international/global health during the past century and a half, mapping out shifts and continuities over time. It then turns to the implications of these changing conceptualisations for current and future global health ideologies, strategies and activities. It concludes by arguing that historians of global health and policymakers need to interact further so that historians are exposed to the contemporary problems of global health and policymakers better understand the historical complexity of extracting ‘lessons’ from the past.     

What future WHO?

New actors on the international health scene have emerged, challenging WHO's leadership in global health. The role and functions of WHO have been questioned. Changes in financing have eroded the influence of the governing bodies. The Nordic countries, which together provide a considerable share of the total voluntary contributions to WHO, have recently made a number of studies of WHO, pinpointing weaknesses and proposing reforms. A slow reform process is also taking place within WHO. The main conclusions from these studies are analyzed and the areas with the greatest need for reform are studied. This paper presents proposals for the far-reaching reforms needed for WHO to recapture its leadership role in international health.     

Re-imagining the "subject:" conceptual and ethical considerations on the participant in qualitative research

The conventional biomedical concept of the "human subject" is out of step with World Health Organization's (WHO) holistic definition of health. The "human subject" in international and national research-ethics policies is a highly individualistic, autonomous person, in contrast to WHO's holistic definition of the healthy person. Qualitative research, this paper suggests, offers a way out of this conundrum. We need to reconceptualize the human "subject" in line with WHO's holistic definition of health. The paper offers concepts of "research participants" derived from qualitative research as an essential way to reconceptualize the human "subject." Moreover, field work, or ethnographic research, as undertaken by qualitative researchers presents a useful way of gaining a fuller understanding of issues of health in a given population.     

Prospects for tobacco control in Zimbabwe: a historical perspective.

Using a historical and political economy perspective, this paper explores the prospects for tobacco control in Zimbabwe, the world's sixth largest producer and third largest tobacco exporter. Tobacco production, which first began in the former Rhodesia in the early 1900s, is closely associated with colonial history and land occupation by white settlers. The Zimbabwe (formerly Rhodesia) Tobacco Association was formed in 1928 and soon became a powerful political force. Although land redistribution has always been a central issue, it was not adequately addressed after independence in 1980, largely due to the need for Zimbabwe to gain foreign currency and safeguard employment. However, by the mid-1990s political pressures forced the government to confront the mainly white, commercial farmers with a new land acquisition policy, but intense national and international lobbying prevented its implementation. With advent of global economic changes, and following the start of a structural adjustment programme in 1991, manufacturing began to decline and the government relied even more on the earnings from tobacco exports. Thus strengthening tobacco control policies has always had a low national and public health priority. Recent illegal occupation of predominantly white owned farms, under the guise of implementing the former land redistribution policy, was politically motivated as the government faced its first major challenge at the general elections in June 2000. It remains unclear whether this will lead to long term reductions in tobacco production, although future global declines in demand could weaken the tobacco lobby. However, since Zimbabwe is only a minor consumer of tobacco, a unique opportunity does exist to develop controls on domestic cigarette consumption. To achieve this the isolated ministry of health would need considerable support from international agencies, such as the World Health Organisation and World Bank.     

Essential drugs: economics and politics in international health

The World Health Organization since the mid-1970s has expanded its activities on essential drugs from a concept to a list to policies, establishing the Action Program on Essential Drugs and Vaccines in 1981. The global social and political environment, especially the emergence of an international consumers movement, created favorable conditions for acceptance of the concept of essential drugs, despite initial resistance by the pharmaceutical industry. The WHO achieved a major accomplishment in getting other organizations to accept the WHO's evolving definition of essential drugs as legitimate. But the relationship between public and private sectors remains a key issue in achieving the objectives of essential drugs policies, an issue the WHO has not fully or directly addressed. Potentials for conflict and collaboration between the WHO and the industry exist around three topics: the extent of regulation, the role of the market, and local production. The case of essential drugs illustrates a new pattern that has emerged for setting the international health agenda, with open participation in international organizations by industry associations and by consumer groups. These changes in the international agenda-setting process influence national policy but still leave difficult problems of implementation at the country level.