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. epi logue 271This narrowing of international health problems to diseases amenable totechnical solutions furthers the notion that public health is a neutral force thatneed only be diffused to underdeveloped settings in order to spur moderniza-tion.5 A technical orientation also has the advantage of being measurable witheach medication or liter of pesticide counted and recorded and thus providesevidence to governing boards of quarterly or annual efficiency.It also meansthat a predetermined method can be applied to multiple settings at once.The conjoined features of outside agenda-setting and the technobiologicalparadigm have led to the model of the vertical disease campaign in inter-national health, whereby hierarchical command-and-control campaigns are organ-ized to combat particular diseases with a single technical tool.While carefullymarshaled resources and a focused target heighten the possibility that endpointswill be reached as planned, separate vertical campaign structures often lead toadministrative duplication and to the neglect of broader and more permanent horizontal public health efforts.The fourth principle is that a priori parameters virtually guarantee the successof cooperative international health activities.Typically projects are time-delimited(RF agreements in Mexico were usually for less than five years), place-delimited(often in locales identified by the likelihood of positive outcomes rather thanhealth needs), and/or particularly important for large-scale campaigns, suchas that against yellow fever include a sunset clause or exit strategy.Togetherwith the focus on particular diseases and technically feasible interventions, theseparameters of success enable cooperative activities to reach a positive outcomevisibly and effectively, ensuring the donor agency s favorable reputation amonglocal and foreign institutional interests, politicians and funders, professionals,and the public.Coupled with the technobiological paradigm, these limits on cooperativeprojects enable international health agencies to show results efficiently andavoid costly, messy, underlying social investments such as those associated withtuberculosis or onchocerciasis (i.e., improvements in housing, sanitation, reloca-tion, etc.) in revolutionary Mexico.This decidedly narrow approach to interna-tional health cooperation persists, even though many professionals and leadersin international agencies and host countries alike recognize that long-term polit-ical and social investments in combination with technical efforts will likelyimprove the public s health more effectively than technical measures alone.A corollary of the limited scope of cooperative projects is the belief, pio-neered by the IHD, that a demonstration activity in a defined area as in amodel health campaign will spur local or national authorities to replicate suchefforts elsewhere in the country.While this expectation yielded few results inMexico, given that domestic agenda-making involved far more than the unfil-tered imitation of international examples, the demonstration approach hasresurfaced in more recent international health efforts as a subsidiary feature tothe other principles.g' 272 epi logueg'The fifth and final principle to emerge from this analysis is the extensiveinvolvement of transnational professionals in cooperative international healthprojects.As seen in the sometimes conflicting case of the RF in Mexico, trans-national professionals are instrumental in building consensus around internationalhealth agendas and serve as interlocutors with regard to particular cooperativeactivities and approaches.Colonial agencies had begun the practice of overseastraining of professionals, but the IHD perfected the fellowship system through arigorous selection process, strict rules on the placement of returned fellows, thetraining of its own staff and international fellows in the same institutions, and themaintenance of ties with fellows through ongoing projects.As former head ofthe IHD Wilbur Sawyer noted in 1949, the training of fellows was begun early so thatleaders will be available for carrying on work later without foreign assistance. 6Transnational professionals became part of international health networks, shar-ing values and understandings of international health with their donor agencycounterparts.Professional training was an ideal concomitant to the other fourprinciples; fellows educated overseas served as leaders and intermediaries forhealth cooperation, able to interact with both international and domestic playersand to translate cooperative activities to the local scene.As we saw in the case of Mexico, the details of these five elements of RF oper-ations outside agenda-setting and extensive donor involvement, budget incen-tives, a technobiological approach, a priori parameters of success, andtransnational professional involvement were challenged and reshaped locallyand in some instances even suspended.Yet the principles took on a normativerole, proving enormously useful for the bureaucratic purposes of reporting andaccountability as well as for the political, economic, ideological, scientific,and humanitarian roles of health cooperation.Regardless of the extensive refash-ioning of particular cooperative activities on the ground, the principles haveendured in the form of a common framework for international health activities.Of course there have been numerous challenges to some of the principles,even at the RF.Just as the IHD was giving way to its heir apparent the WHOin the late 1940s, several internal assessments ventured toward a rather differentapproach to international health cooperation.In a 1947 IHD-commissionedstudy on international health insurance trends, its longtime China and SouthAfrica officer John Grant called for a social medicine approach, whereby thesocial dimensions of human needs ranging from universal health services to aminimum wage and to housing and nutrition needs would be integrated withmedicine and public health.7Two years later, an internal report on Efforts to Help Backward Peoples toHelp Themselves admitted that the IHD had erred in setting cooperativehealth agendas unilaterally, for IHD men hada maximum sense of our own power, our own interest, our own goodness, and our ownknowledge.We have very little knowledge of the parties of the second part their social epi logue 273systems, their human relations situations, their resources in personnel, their philoso-phies and values in life.Our conceit and our desire for speed give us very little readi-ness to study these matters before acting.Yet, the delivery end is one of the crucialpoints of the whole problem.8Even IHD malaria officer Paul F.Russell, who would become a key player inthe WHO s global malaria campaign, acknowledged confidentially in 1950 thatthe IHD s long-standing practice of budget incentives was unrealistic, for It isdifficult for governments of underdeveloped countries to find money for exper-imental projects. 9By the time these critiques surfaced, the donor-driven, matching-fund-based,narrowly technical approach had become further entrenched.10 World War II sinauguration of penicillin, and the successful use of DDT against louse-bornetyphus and malaria generated renewed confidence in technical means toaddress public health problems, disease by disease.11 Rather than disappearingwith the demise of the IHD in 1951, the RF principles of international healthcooperation found an institutional home in the WHO
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