Outside the Family of Nations: First Thoughts on Writing a History of Public Health from the Perspective of Outlier Nations

Abstract

Notwithstanding the current declarations by spokesmen for and proponents of global health, there remain “outlier” countries: countries unwilling to accede to monitoring or surveillance (e.g. China and avian flu; China and SARS); countries lacking the infrastructural and professional capacity to join cooperative global programs to fight epidemics; countries/regions that have populations with divergent approaches to health goals and practices. What, if any, are the historical precedents of the idea of “outliers”? The paper will argue that in the three decades between 1920 and 1950, internationally-minded statesmen, working in philanthropies with transnational “reach” or in international health agencies, operated with two additional categories of outliers. First, countries with political systems judged “inimical” to democracy (e.g. Soviet Russia, post-war Germany). International public health statesmen often engaged such countries by hiving off (at least notionally) the political system from public health. What was the cost to the understanding of public health of the hiving off of the political? At other times, international health spokesmen explicitly linked transnational cooperation/assistance they offered to a program of democratization. To what extent was that linkage accepted by leading health voices in the target countries? Second, there were countries whose health “civilizations” had not yet progressed fully beyond nineteenth century public hygiene. Including these countries in international health programs involved nothing less than pushing out the frontiers of civilization. In dealing with these countries, health statesmen operated with the initial assumption that capacity and orientation to social medicine could be shaped from the outside. Extended experience on the ground (site visits, field work, cooperative programs) convinced those statesmen of the value of local (and regional) approaches and of the possibility of combining those approaches with international ways of conceptualizing public health. What factors shaped the inclusion/exclusion of countries from the category of “civilized” nations?