Between 1918 and 1940 Latin America became a testing ground for one of the most ambitious and controversial concepts in modern public health: disease eradication. The eradication of infectious diseases in Latin America became a popular endeavour among many US public health authorities of the early twentieth century. This concern arose for a complex combination of technical and political reasons which included the success of local eradication efforts earlier in the century (e.g., those carried out in Havana and Panama at the turn of the century), the fear of Latin America infecting or reinfecting the US, and the perceived need to protect those areas of the world which the US considered under its economic influence.

Partially because of the absence during the 1920s and 1930s of an effective international framework through which Latin American countries could act on common health problems, the Rockefeller Foundation (RF) played an active role in the emergence and application of the eradication concept (the Pan American Sanitary Bureau, created in 1902, functioned until the early 1930s with a small staff and as a virtual branch of the US Public Health Service). The RF's eradication campaigns had several by-products such as the reorganisation of Latin American public health institutions, the expansion of public health services to rural areas, and the shift of the academic and technical centre of influence from France to the US.

The underlying aim of much of the work of the Social Section of the League of Nations was to improve the quality of life of women and children. Proposals put forward to reach this goal reflected assumptions about gender roles and relations as well as changing ideas about the role of the state in sustaining them. Recent comparative research on social welfare policies and programmes of western European countries and the United States between the 1880s and the end of the Second World War has demonstrated the importance of considering both the role of women in social welfare movements and the visions of gender embodied in the state-sponsored social policies that emerged. Popular notions about women's special capacity as actors in the social field also led to women's extensive participation in the social committees of the League of Nations (LN). The decision to appoint a woman, Dame Rachel Crowdy, as Chief of the Social Section was a conscious one. Unlike all other LN permanent advisory committees, women usually enjoyed equal representation on the social committees. In the same way, many government delegations to the LN Assembly included women who were then appointed to the Fifth Committee (Social Questions). The Social Section actively solicited the support of women's organisations in connection with the work of the social committees and many of their proposals were taken up by the League.

Developing a discourse

The present preoccupation with child abuse and the discussion on the best means of protecting child life merely elaborate a rhetoric whose antecedents are in the nineteenth-century child-saving movement which flourished in industrialised nations. A study of international child protection organisations illustrates the continuity of such rhetoric which moved from a sentimental depiction of victims to a medico-social scientific discourse of children at risk that expanded the concepts of victimisation, exploitation and abuse.

It is through discourse that social claims become persuasively defined and social conditions are identified and transformed into social problems whose advocates lobby for recognition of the priority of their claims.

Introduction

The Eastern Bureau of the League of Nations Health Section was established in 1925 to collect and disseminate epidemiological information. Until February 1942, when Singapore was invaded by Japanese troops, the Bureau served a variety of functions; the receipt, compilation and dissemination of health statistics, quarantine procedures and other information related to the control of disease were only part of its wider role. Its functions included the co-ordination and review of scientific research; the provision of in-service training of sanitation, public health and medical officers through staff interchanges, study tours and from 1934 annual short-course training programmes for malariologists; and sponsorship of and participation in scientific conferences and symposia. Through these various activities, the Bureau helped to identify the primary public health concerns of the region, facilitate co-operation between individual researchers and research institutions, and develop public health expertise. Less easily documented, the Bureau also played a role in fostering a sense of common purpose among countries in the region. Its primary function and central activity, however, as noted, was the collection and dissemination of epidemiological information; this is the focus of this chapter.

The Commission of Enquiry in the Far East

Epidemic disease in East Asia was first brought before the Health Committee of the League of Nations (LN) at its second session in October 1921, when the Japanese delegate, Dr Miyajima, drew attention to the incidence of pneumonic plague in Manchuria and Siberia.

Whereas the development of welfare states has been the subject of sustained academic scrutiny, international aspects of welfare have been much neglected. It is possible for national systems to retain a diversity of locally administered elements (for example, involving municipalities, social insurance corporations or occupational health schemes) while providing centralised funding and administrative and legal frameworks. But international organisations have vital roles and demand far greater attention from historians and social scientists than they have hitherto received.

As any localised system could suffer from inequalities and lack resources, and states could manipulate health and welfare issues for the purposes of political expediency, international organisations became an attractive option for promoting reforms. International bodies may remedy local deficiencies, set optimal standards and improve the quality of the systems of care and the training of personnel. While some of these functions can be fulfilled by the state, it should be recognised that the state as a provider of welfare can be problematic, because its multifunctional character may render health and welfare low political priorities, or distort welfare as caught up in the politics of interest groups and financial expediency. The interwar rise of fascist and kindred authoritarian regimes that perverted welfare systems for purposes of political discrimination and genocide was in marked contrast to the humane ideals of internationalists.

The Italian War of 1859 helped to create the Red Cross; the First World War precipitated efforts to reorganise it. These may be divided into two quite different categories: those which sought to consolidate and extend the traditional role of the International Committee of the Red Cross (ICRC) and the national societies, and those which asserted the need to create a new kind of Red Cross for the anticipated new era of peace and international co-operation. Support for the idea of a limited reorganisation came primarily from the ICRC (entirely Swiss in membership since its inception in 1863), and from the national Red Cross societies of the smaller European states; proposals for a much more ambitious reform came principally from America and Japan. What rapidly took shape was a power struggle between the Red Cross societies of the victorious Allies, led by the Americans, and the ICRC, which understandably feared for its own survival if the reformers were to triumph. In one form or another, this struggle lasted until 1928, when a settlement of the main issues was finally reached.

More was at stake in this conflict than was apparent on the surface: at its heart lay a fundamental disagreement over what role the Red Cross ought to play in modern society.

The essays in this volume arise from a recent convergence of interest in the history of international health and welfare organisations. The sheer diversity of organisations and their many-sided activities make this a rich and complex area of historical investigation, which has direct relevance to current issues in international health

Although contributors to this volume are dispersed throughout the world, an informal network arose in what is very much a new field of study. I therefore wish to express my appreciation of how contributors have co-operated to bring this volume to fruition within a relatively short period of time. The exchange of papers meant that there was much interchange on topics of mutual interest, while perspectives have remained refreshingly diverse. I am particularly indebted to contributors for comments on my introduction and my essay on social medicine. It meant that arguments were refined, and, in order to avoid duplication of analysis on central issues, several contributors generously agreed to omit material dealt with elsewhere in the volume. Their efforts have meant that an exceptionally cohesive, integrated and intellectually coherent volume has taken shape. It is hoped that this collection will provide solid foundations for other projects on twentieth-century international health that are already under way.

Between the two world wars health services in Europe and America began to extend from institutional care of the seriously mentally disordered to cover early treatment of less serious cases, after-care of recovered cases and organised care in the community. Even more ambitiously, there was an expansion of interest in prevention of mental disorder and promotion of environmental conditions to encourage positive mental health among the normal population. A variety of terms were used to describe these new approaches: in Britain a tradition of charitable and local government economic assistance shaped the emergence of ‘mental welfare’ and ‘community care’; in the United States Adolf Meyer adopted the term ‘biopsychiatry’ to reflect his holistic approach; in France the terms used were ‘mental prophylaxis’ and ‘psychotechnics’; and in the Soviet Union it was ‘psychohygiene’. However, the most popular and all-embracing term used to describe these developments was ‘mental hygiene’.

The simultaneous adoption of mental hygiene strategies was partially the result of common reactions to social and welfare problems of the interwar period. However, the pace of socio-economic and political modernisation was not even. It is therefore worthwhile considering whether parallel developments were, instead, the result of an international mental hygiene movement. This chapter will consider the extent to which there was an international movement and its interaction with national mental hygiene movements and organisations.

The Epidemic Commission of the League of Nations (LNEC) was considered at the time of its creation to be the ‘first essay in international cooperation’, in that, contrary to other health and relief organisations, its funds proceeded not from a charitable public, but from national governments. The Commission acted exclusively through local health administrations, basing its work on ‘the necessity of strengthening the public health and sanitary organisation of the country as the most effective and the most lasting means of checking the spread of epidemics’. Although the Epidemic Commission lasted little over three years (April 1920–December 1923) and worked in only five countries (Poland, Soviet Russia and Ukraine, Latvia and Greece), it marks one of the early ‘success stories’ of the League of Nations Health Organisation (LNHO) which it preceded and, indirectly, had a large part in creating.

Typhus and the First World War

The Epidemic Commission (initially called the Typhus Commission) was born to fight the louse, as the vector of typhus, a rickettsial infectious fever which leads ‘the quiet bourgeois existence of a reasonably domesticated disease’ in times of peace and flares up into epidemics when basic sanitary conditions break down.

Throughout the nineteenth century the international sanitary order had relied on quarantine and the surveillance of travellers and goods. More than half a century of international sanitary conferences, in all twelve meetings from 1850 to 1912, can be summarised as leading to the establishment of sanitary cordons against all pestilences coming from the East and an attempt to control migration, in particular the great pilgrimages.

The First World War fostered a new type of interest in international health with the recognition of the devastating potentialities of epidemic agents on multitudes thrown together in a giant battlefield. The Balkan experience was crucial in that it exposed millions of men, coming from all countries in the world, to a wide range of epidemic hazards, including water-borne diseases, typhus and malaria.

Two kinds of considerations, political and epidemiological, rendered the sanctuarist view pointless:

The pacifist wave after the Treaty of Versailles led to the perception of public health as an ingredient of civilisation and a condition of international peace.

The problem of social medicine: radical reform or authoritarian interventionism?

The aftermath of the First World War saw a transition from the control of epidemic, infectious diseases to international endeavours promoting social medicine. It was hoped that international peace could be underpinned by alleviation of social deprivation and injustice: effective health and welfare services were intended to stabilise the existence of new states and modernise administrative structures. State administrations adopted ambitious plans to extend social welfare provisions; and a private sector that had been heavily engaged in war relief work attempted to shift the basis of voluntary care away from philanthropic aid, and towards tackling the scientific roots of poverty and disease. The new priority given to maternal and child health, and to the prevention of chronic degenerative diseases (notably tuberculosis and certain sexually transmitted diseases) was linked to a range of demographic and social issues. Visionary schemes promoted innovative concepts of positive health and diverse concepts of ‘social hygiene’, ‘social medicine’ and of a healthy ‘human economy’. Clinical medicine was to be ‘reconstructed through social science’, and the organisation of medical care was to be collectivised by state and municipal public health physicians superintending polyclinics and public hospitals.

Whatever the prevailing political system, there was an international consensus among public health experts that the collectivisation of health care should look to advances in biological and social sciences.

‘Without the devoted personal service, the disinterested counsel, and the co-operation of experienced nurses who went out from America to the Far East, Continental Europe, and Latin America, public health nursing could not have achieved the relatively high status it now occupies in these areas.’ Such was the confident conclusion of Rockefeller officials in 1938, after twenty-four years of Rockefeller interventions in nursing. In this chapter I shall consider the role of the Rockefeller Foundation (RF) in promoting nursing education in England during the interwar period. This episode in RF history was marked by the competitive interplay between a number of international organisations keen to influence the pattern of nursing education. Organisational rivalry and constraints on resources undermined attempts to establish an international infrastructure for nursing education. Moreover the low prestige attached to nursing by the RF circumscribed any investment the Foundation was prepared to make and ultimately the results that could be achieved.

Nevertheless the ‘imperial gaze’ of the RF ranged far and wide across the realm of nursing, scanning England and certain parts of Central and Eastern Europe for opportunities to invest. Scotland, Wales and Northern Ireland fell outside the RF's immediate scope of nursing vision. In spite of its emblematic status as the centre of the British Empire, England proved disappointingly barren territory for Rockefeller's expansionist ambitions.

An elite of biomedical and health specialists functioning through the League of Nations Health Organisation (LNHO) in the interwar decades contributed to the development of the public health profession. They served as a co-ordinating body — a sort of executive committee — for a worldwide biomedical/public health episteme that recently had acquired confidence in its ability to alleviate human suffering by reducing, if not eliminating, disease. This new confidence reflected new consensual knowledge about the aetiology and epidemiology of many diseases and the physiological conditions and socio-economic factors contributing to human illness. It stimulated their humanitarian instincts, leading them to devise the LNHO, a novel institution at the centre of the interwar health regime. This regime had the unusual quality of being largely self-transforming in response to new scientific knowledge developed within the episteme. It also led to the creation in various countries of new national health institutions.

Health co-operation before 1919

During much of the nineteenth century, little consensual knowledge existed about the causes of illness or how diseases are transmitted. The social devastation and fear generated by plague and cholera, nevertheless, induced some governments to seek protection against epidemics emanating from the Middle and Far East and Asia Minor. Diverse, arbitrary, and often contradictory opinions about these diseases prevented effective action.