International Efforts to Control Infectious Diseases, 1851 to the Present

Recent history has shown that, despite claims of conquest, infectious diseases are far from a relic of the past. According to the World Health Organization (WHO), every 60 minutes, 1500 people die of an infectious disease.^{1 - 2} Not only have old epidemics, such as tuberculosis, malaria, and measles, recrudesced but also newly emerging diseases, such as West Nile fever, Ebola fever, and severe acute respiratory syndrome (SARS), have appeared around the world and demand new interventions and strategies. In addition, for the past 2 decades AIDS has killed and debilitated millions of people and exposed the limits of scientific knowledge and its therapeutic applications.³

Throughout the past few decades especially, framing approaches to controlling newly emerging and reemerging infectious diseases in terms of globalization and modern transformations in international commerce, transportation, and human migration has become commonplace.^{4 - 6} There is certainly a great deal of truth to such assertions. For example, the outbreak and containment of SARS in the spring of 2003 was facilitated by new global technologies such as transoceanic air travel (which can allow microorganisms to travel from country to country and provide them with a propitious environment to incubate and spread) and the Internet (which greatly enhances the potential for epidemiologic surveillance and rapid communication between distant laboratories). However, we argue that it would be a mistake to view today's approaches to controlling infectious diseases solely through the window of the past few decades. We illuminate a more extended history by exploring the origins of international efforts to combat infectious diseases, and concomitantly promote health, during the past 150 years.

This historical survey illustrates the extent to which national interests, political or cultural beliefs, scientific debates, and financial concerns have hindered and helped the world's ability to confront and quell infectious diseases. Tracking international responses to infectious diseases during the past century and a half, from cholera in the 19th century to SARS in the 21st, underscores that triumphal narratives of human and medical progress are misplaced. Sadly, the lack of authority to enforce coordinated responses to epidemic outbreaks around the world and a weak system of incentives for public health investment have limited the capacity of international health organizations since their inception. We review 3 eras of international approaches to controlling infectious diseases (1851-1881, 1881-1945, and 1945 to the present) and conclude by suggesting why strong incentives are needed to encourage nations to invest in health programs and infrastructures in and beyond their own borders.

As people began to travel and trade, the microorganisms and infectious diseases they harbored traveled with them. For example, the spread of bubonic plague epidemics during the Middle Ages was linked to human migration patterns and the resulting development of quarantine laws.⁷ The mere threat of an impending plague visitation typically prompted the closure of entire ports and cities to foreign travelers and goods.⁸ In the 15th century, along with plans for colonization and evangelization, Spanish conquerors imported microbial diseases such as smallpox and measles that decimated native populations in the Americas.⁹ After the boundaries of modern nation-states began to crystallize in the 18th and 19th centuries, improving global health became integral to national welfare and international diplomacy.^{10 - 11} Many leaders of nation-states began to accept that controlling the spread of infectious diseases from one nation to another required international solutions and organized international conventions and draft covenants, almost all of which related to quarantine regulations.¹² Conflicts frequently arose as nations sought to balance territorial sovereignty and economic interests with the need for transparent and universally applied health protections.

Cholera, which ravaged Asia and Europe in successive waves in the early to mid-19th century, inspired physicians and politicians to convene the first International Sanitary Conference in 1851.^{13 - 14} Representatives from 11 European countries met in Paris to formulate a utopian quarantine policy capable of simultaneously curtailing the transnational importation of diseases and upholding the imperatives of trade and commerce. The practical results of this gathering were limited because scientific disagreement about disease etiologies, coupled with the mercantilist prerogatives of participating nations to protect their boundaries and commerce, stymied the elaboration of mutually acceptable measures.¹⁴ Nonetheless, this inaugural conference was instrumental to the formation of the first international network of scientists and policy makers devoted to the global control of infectious diseases and should be recognized as the cornerstone of today's multinational health organizations.

From 1851 to 1900, 10 international sanitary conferences were held, with each successive meeting drawing more delegates.¹⁴ These meetings focused exclusively on the containment of epidemics, and their specific agendas varied, depending on whatever disease outbreak (cholera, plague, or yellow fever) was most urgent. As Howard-Jones¹⁴ has pointed out, these gatherings provide a window onto a transitional moment in modern medicine when the previously stark lines between contagionist and anticontagionist doctrine were becoming increasingly blurred. The same disease agent could in one afternoon session be referred to as a germ, miasm, animalcule, zymotic poison, microphyte, seed, fungus, or virus.^{14 - 15} In their search to ascertain how germs were transmitted, delegates formulated intricate, if convoluted with hindsight, theories. For example, one of the most prominent participants at these meetings, the German scientist Max Von Pettenkofer, can be most aptly described as a "contingent contagionist."^{14 - 15} He maintained that cholera was spread through contaminated groundwater, a theory that combined persuasive elements from various models of disease causation.¹⁶ Whatever theory they endorsed, however, delegates sought to formulate transnational quarantine procedures and mechanisms. Nonetheless, divergent theories and the belief that noxious elements in the environment were responsible for disease or that particular ailments were geographically specific often militated against consensus.

Decades before the articulation and demonstration of germ theory, these meetings presaged many of the organizational structures of contemporary public health administration that are taken for granted today. They encouraged the formation of national health agencies with designated delegates who were dispatched to international meetings and shared findings upon returning home. More important, they set the stage for the eventual establishment of standardized definitions of quarantine and systems of information gathering and disease surveillance. Despite intellectual, personal, political, cultural, and linguistic differences, delegates demonstrated a shared commitment to continue to reassess critical health issues against the backdrop of rapidly changing scientific theories and discoveries. For example, it is easy to forget that the public health methods often endorsed before the germ theory era, although inspired by sanitarian concepts such as cleaning up the streets and purifying the food and water supply, had a salubrious effect on health indicators and reduced endemic and epidemic diseases.^{17 - 18} Indeed, these are proven measures that have the advantage of targeting many social and structural conditions that can give rise to disease and could benefit many developing countries today.

During this era, international health endeavors were propelled by technologic developments, such as the telegraph, telephone, and typewriter, as well as new modes of transportation, particularly the railroad and steamship lines. However, there was a negative underside to this period of scientific and technologic change because some of the most spectacular medical and scientific gains of the 19th century were frequently enmeshed with colonialism and imperialism.^{19 - 20} Africa, Asia, and the Caribbean often served as laboratories for experimentation and human and animal subject research that today we would find disturbing. For example, European missions were sent to Egypt and India to investigate cholera; the plague bacillus was isolated in Hong Kong, independently, by a Frenchman and a Japanese bacteriologist; and the insect-vector transmission theory of yellow fever was confirmed in the wake of the US military occupation of Cuba and the Panama Canal.^{20 - 24} Today, we all benefit from these medical discoveries. But we should not forget that they were made during the zenith of European and US colonialism and were one part of a constellation of interventions aimed, at least in part, at improving the health and productivity of laboring populations and enhancing commercial and territorial dominion.

Not surprisingly, the emphasis of the international sanitary conferences was determined by the most deadly infectious disease of the day. The first 4 meetings in 1851, 1859, 1866, and 1874, for example, concentrated almost exclusively on cholera, the great infectious scourge of the 19th century.^{14 ,25} At the 1881 conference held in Washington, DC, on the other hand, US delegates brought attention to yellow fever because it had broken out in epidemic proportions in the Mississippi River Valley 3 years earlier.^{14 ,26 - 27}

By the 1890s, delegates had built functional working relationships and increasingly shared the same scientific and legal vocabulary, and, as a result, substantive consensus on international sanitary and quarantine regulations began to emerge.^{13 - 14 ,28} As more and more delegates accepted the germ theory of infectious disease, they were more likely to agree on rudimentary measures for containment and control. Hence it was at the 1892 meeting that the first International Sanitary Convention, dealing exclusively with cholera, which had just appeared in pandemic proportions, was signed.^{13 - 14} Five years later, at the 10th International Sanitary Conference, a similar convention focused on plague was drafted and signed. Plague was of particular concern that year, given the recent outbreaks in India and the announcement that Alexandre Yersin, a Swiss bacteriologist and protégé of Louis Pasteur, had identified its etiologic agent.¹⁴

Even if the international sanitary conferences, which were held until the eve of World War II (1938), resulted in relatively few long-lasting agreements and conventions, they influenced international health in myriad ways. First and foremost, they served as forums in which the latest findings about bacteriology were announced and deliberated.^{10 - 11 ,13 - 14} As scientific luminaries such as Louis Pasteur, Robert Koch, Carlos Finlay, and many others shared their revolutionary discoveries about the leading infectious killers of the day, delegates initiated the formulation of a modern, scientifically informed, international canon of quarantine regulations, medical inspection of travelers and goods, disease surveillance methods, and disease classification.^{13 - 14 ,28 - 29} In many cases, these new techniques of infectious disease control were codified into national law and informed the missions of regional and service organizations. In the United States, for example, medical inspection, quarantine, and laboratory standardization went hand in hand with the gradual federalization of public health, away from local and state entities to the US Public Health Service (USPHS).³⁰ Indeed, it is only against the background of medical internationalism that we can begin to understand the elaboration of USPHS regulations on immigrant inspection, quarantine, and vaccination during the early 20th century.³¹

In 1902, greater hemispheric cooperation, particularly with respect to yellow fever, led to the creation of the Pan American Sanitary Bureau (now called the Pan American Health Organization, or PAHO), which soon became a model for transnational health promotion and information sharing.^{32 - 35} Across the Atlantic Ocean, the Office International d'Hygiène Publique (OIHP), based in Paris, was founded in 1907 to collect and disseminate data about infectious diseases to strengthen quarantine and other global public health regulations.^{13 - 14} The OIHP functioned chiefly as an international information clearinghouse and by World War I was systematizing the latest findings on malaria, typhoid, hookworm, tuberculosis, and other health threats.

After World War I, the League of Nations formed a Health Committee in which individual US physicians participated, but not the United States at large because of the decision by the US Senate not to ratify membership in the league.^{13 - 14} However, despite friction and redundancy between the League of Nations Health Committee and the OIHP, the 2 organizations collaborated to launch international health studies and encourage demonstration projects in afflicted regions of the world and were pivotal to the elaboration of modern international disease classifications. Alongside the health campaigns of the International Labor Organization and the International Red Cross, the Pan American Sanitary Bureau, the OIHP, and the league's Health Committee began to broaden the international health portfolio to consider maternal and infant health, nutrition, housing, physical education, narcotic trade and addiction, and occupational health.^{13 - 14 ,36 - 37} Their work was substantially complemented by the International Health Board of the Rockefeller Foundation, which sponsored projects targeting many tropical diseases, especially malaria and hookworm, in countries such as China, Brazil, and Mexico.³⁸ These organizations concentrated on the control of infectious diseases, and health officers undertook their eradication and prevention efforts with vigorous determination.

During the construction of the Panama Canal from 1904 to 1914, for example, US physicians and scientists took far-reaching measures to eliminate any source of standing water where mosquitoes could breed.^{22 - 24} Although the US public health efforts in the Canal Zone were stunningly effective in quelling yellow fever through mosquito eradication, this success came at the cost of neglecting more mundane but just as deadly maladies such as pneumonia and diarrheal diseases, a pattern that has frequently been repeated in the decades since.³⁹

Furthermore, during this era, infectious disease interventions sometimes converged with distorted assumptions about race, ethnicity, and class that reflected and perpetuated inequities in health status and access. In the United States, for example, particular immigrants were often viewed as the vectors of particular diseases even as bacteriology continued to demonstrate that microbes were the most egalitarian of living beings when it came to finding a host to infect.^{40 - 41}

Despite these problems, however, by the 1930s the reforms and campaigns promoted by international, national, and local health agencies, along with new technologic and scientific developments, were reshaping the international health landscape.^{10 - 11} Even before the introduction of antibiotics and the development of many vaccines we take for granted today, the worst scourges of the past, such as tuberculosis, bubonic plague, and cholera, began to diminish around the world. This trend only intensified with the emergence of penicillin and the mass production of a host of antibiotics. In the aftermath of World War II, as the brutalities that took place in the Nazi death camps began to be widely reported, nations collectively pledged to prevent such human brutality in the future. This humanitarian movement led to an unprecedented degree of international cooperation that would be harshly tested by the vicissitudes of politics, the global economy, and a wide spectrum of deadly, chronic, and debilitating diseases.

When the United Nations Conference was convened in San Francisco in 1945, delegates unanimously concurred that a single global health organization should be founded and recognized as an essential component of the postwar international system.^{42 - 43} Toward this end, members of the Pan American Sanitary Bureau, OIHP, the league's Health Committee, and a few additional organizations were entrusted with drafting a constitution for the proposed WHO. WHO's constitution was signed the following year at a conference in New York City and ratified in 1948, and shortly thereafter, WHO's premier body, the World Health Assembly, gathered for its inaugural meeting in Geneva.⁴⁴ Its charge was to foster and coordinate public health campaigns across the world, in large part by spearheading cooperation between nations and fomenting national health agencies.^{42 - 45} Moreover, WHO's mission was guided by a new definition of health, which was now seen not just as the amelioration of disease but also, more positively and broadly, as the promotion of universal physical, mental, and social well-being.^{42 - 45} This redefinition was facilitated by the medical advances of the past century, as well as an explicit emphasis on human rights, which acquired heightened meaning after worldwide recognition of the horrors of the Holocaust.⁴⁶ Individual and collective health was now considered by representatives of the United Nations to be "fundamental to the attainment of peace and security."⁴⁵

WHO subsumed its predecessor organizations to become the world's officially sanctioned public health organization. WHO established 6 semiautonomous regional offices, taking its cue from the USPHS, which had long maintained geographic district offices.⁴⁷ PAHO was incorporated under WHO's umbrella in 1949, followed by offices for Europe, the western Pacific, Africa, the eastern Mediterranean, and Southeast Asia.^{42 - 43} Recognizing the necessity to combat infectious diseases, in 1951 WHO adopted a revised version of the International Sanitary Regulations first approved at the 1892 international sanitary conference. However, this set of regulations was originally created specifically to control cholera, plague, and yellow fever and still remains in effect today, demonstrating the degree to which present approaches to controlling infectious diseases are rooted in and potentially constrained by their 19th-century antecedents.⁴⁸

During its early years, WHO had high hopes of using the latest biomedical techniques and advances in the quest to eradicate infectious diseases and improve basic health indices. Its initial major campaigns included the containment of yaws, which, thanks to penicillin, was spectacularly achieved and transformed the lives of millions of afflicted children, particularly in Africa and the Caribbean. Emboldened by the success of this "magic bullet" approach and perhaps too much faith in microbiological or pharmacologic solutions, rather than combining these efforts with programs of broad social interventions, WHO spent its first 2 decades launching similar disease-specific campaigns, principally targeting tuberculosis, malaria, and smallpox.⁴⁹

One of WHO's greatest triumphs was the smallpox eradication drive that culminated with the last naturally occurring case in Somalia in 1977.⁴⁹ But these efforts also demonstrated the crucial role that local health workers play in any treatment or vaccination program. Similar efforts to contain malaria demonstrated just how socially complex the task of mosquito control could be. Hence it was the experiences among WHO scientists, community health organizers, and the local populations that helped to generate awareness of the dire need for improved health infrastructure, culturally sensitive public health campaigns, and the availability of primary medical care.^{49 - 50} Along these lines, by the 1970s postwar optimism had faded and was gradually replaced by an awareness that the eradication of specific diseases would translate into few if any gains in regions that lacked sewage systems, potable water, adequate food, health clinics, and rudimentary knowledge of illness and treatment, to name but a few crucial positive contributors to a population's general health. For example, after the famine in Biafra and its disastrous aftermath during the early 1970s, dissatisfaction with the failure of WHO and the International Red Cross to address the structural and political precipitants of health catastrophes prompted a group of French physicians to found Médecins San Frontières (Doctors Without Borders).⁵¹

Eager to move beyond the limits of disease-specific approaches, WHO consciously shifted its course in 1977, when the World Health Assembly resolved that "the main social target of governments and WHO in the coming decades should be the attainment by all the citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life."⁵⁰ The following year, delegates from 134 countries, 67 United Nations organizations, specialized agencies, and nongovernmental organizations gathered in Alma-Ata, in present-day Kazakhstan. There, Dr Halfdan T. Mahler, WHO's director-general, challenged participants to address the social, economic, and cultural problems that produced and reinforced the marked discrepancies "between the health ‘haves' and ‘have-nots'" around the world.⁵⁰ At this historic meeting, delegates—many from African nations that had recently gained their independence through anticolonial struggles—pronounced their commitment to creating a health-for-all value system and working toward making access to health care a reality for everyone.^{50 ,52}

Since the Alma-Ata summit, WHO's achievements, particularly immunization of children in third world countries, have been clouded by the difficulty of the dual goal of diminishing specific infectious diseases and delivering basic health services to impoverished areas. WHO's mission has also been hindered by bureaucratic logjams, geopolitical tensions, internecine religious and ethnic warfare, and ongoing if not worsening economic disparities between the developed and developing world.^{1 ,3 - 4 ,53}

In the 19th century, international health conferences and the drafting of quarantine and sanitary conventions produced the first set of global strategies and regulations for combating infectious diseases. By the 20th century, these gatherings had played a central role in the standardization of disease classification and surveillance methods. However, rifts and rivalries between nations too eager to blame foreigners for disease or hesitant to implement a quarantine on their own shores because of lost commerce and tourism often undermined the efficacy and relevance of international health provisions. Moreover, since their inception in the mid-1800s, international health organizations have lacked the supranational power to require nations to follow internationally mandated health conventions.⁴⁸ In the case of WHO, for example, many would argue that acting as the global medical police contradicts its charter and commitment to the protection and promotion of human and civil rights.

Given the rise of newly emerging and emerging infectious diseases and that it is unlikely that WHO will possess such unilateral authority in the near future, we must identify incentives to encourage substantial investments in the battle against infectious diseases and work as a global community toward achieving health as defined by WHO in 1946. Nothing less than a cooperative partnership of nations, health care professionals, medical researchers, public health specialists, and concerned corporations and individuals will suffice.^{1 ,6} Much more can be done to prevent and treat many infectious diseases, provided nations are prepared to make the necessary financial and social commitments to the task.⁵⁴ Tens of thousands of dedicated health workers affiliated with WHO and other global health organizations have been working toward such goals for decades now, but in our shrinking world all health practitioners and policy makers must view international health as a local concern, which necessitates an umbrella approach that involves philanthropic organizations; economic foundations; nongovernmental organizations; national, regional, and local medical societies; academic institutions; service organizations; and citizens. As concerned health care professionals, we can put the movement of globalization to good use in the battle against infectious diseases. Specifically, with the rise of global markets where people, goods, services, and information now flow routinely and swiftly across regional and national borders, there is a greater need for transparency and accountability not only in economic matters but also in terms of infectious disease control. Indeed, this is one of the historical lessons of the SARS epidemic of 2003.

In September 2000, the United Nations held a Millennium Summit in which leaders of 180 nations set several goals for promoting the health of all the world's citizens by 2015. Among these were controlling epidemic diseases, reducing the world's childhood mortality rate by 66% and the mortality rate of women during childbearing by 75%, reversing the global spread of AIDS, and halving the proportion of people in the world who have no access to safe drinking water or adequate food and whose income is less than $1 a day.⁵⁵

Columbia University economist Jeffrey Sachs was asked to develop a Commission on Macroeconomics and Health for the United Nations to begin accomplishing these noble and lifesaving aims. The commission's 3 core findings were elegantly simple, though hardly simplistic. First, the massive amount of disease burden in the world's poorest nations poses a huge threat to global wealth and security. Second, millions of impoverished people around the world die of preventable and treatable infectious diseases because they lack access to basic medical care and sanitation. And third, we have the ability and technology to save millions of lives each year if only the wealthier nations would help provide the poorer countries with such health care and services.⁵⁶

What Sachs and his colleagues projected, in terms of dollars and cents, is that all of the wealthy nations of the world must devote one tenth of 1% of their gross national product (or $0.01 for every $10 of income) toward supporting health services for the world's poor. Economists estimate that the combined income of the world's wealthiest nations is about $25 trillion a year. Thus, a multinational contribution of $25 billion a year, along with similar monetary donations from philanthropic and corporate resources and cooperative efforts from poor nations, could markedly reduce the world's disease burden; 21 000 lives could be saved each day under such a plan.^{57 - 58} If the humane imperative is not enough, recall that with enhanced worldwide health, vast improvements are made in the world economic situation because of more productive labor forces in nations decimated by disease. If this task were begun today, the United Nations Commission estimates that by 2020, more than $360 billion dollars a year would be generated in other economic benefits.⁵⁹ More recently, 8 internationally renowned economists, including 3 Nobel Prize winners, met in Copenhagen to determine how $50 billion could be most effectively spent on improving the world in any way, including education, the environment, and social services. According to cost-benefit analysis, they determined that the 3 best investments were $27 billion for combating AIDS, $12 billion for malnutrition, and $13 billion for malaria.⁶⁰

These endeavors can work. The global effort to eradicate smallpox through immunization programs was a stunning success. Recent programs organized by a consortium of foundations, health agencies, and pharmaceutical companies to reduce or eliminate African river blindness, trachoma, AIDS, and leprosy in developing nations have been extremely successful.¹ Nevertheless, one of the greatest challenges of the 21st century is to construct a global health organization, or set of organizations, to expand and refine the activities initiated more than 150 years ago at the first international sanitary conferences. With an understanding of the close association between health and human rights, as articulated by the United Nations and WHO, and the best practices of infectious disease control, as demonstrated over time, there is hope as long as the world community accepts the fact that investing in infectious disease control is critical to global health, security, and prosperity. As the early 20th-century public health pioneer Dr Hermann Biggs proclaimed in 1911, "Public health is purchasable."⁶¹ But it is an investment that works best when purchased in advance rather than paid out as each crisis arises.