Backstage: the relationship between the Rockefeller Foundation and the World Health Organization, Part I: 1940s-1960s.

In recent years, there has been a growing debate about what role foundations should play in global health governance generally, and particularly vis-à-vis the World Health Organization (WHO). Much of this discussion revolves around today's gargantuan philanthropy, the Bill and Melinda Gates Foundation, and its sway over the agenda and modus operandi of global health. Yet such pre-occupations are not new. The Rockefeller Foundation (RF), the unparalleled 20th century health philanthropy heavyweight, both profoundly shaped WHO and maintained long and complex relations with it, even as both institutions changed over time. This article examines the WHO-RF relationship from the 1940s to the 1960s, tracing its ebbs and flows, key moments, challenges, and quandaries, concluding with a reflection on the role of the Cold War in both fully institutionalizing the RF's dominant disease-control approach and limiting its smaller social medicine efforts, even as the RF's quotidian influence at WHO diminished.

School placement for human immunodeficiency virus-infected children: the Baltimore City experience.

Over the past 6 years, the city of Baltimore has successfully implemented a school placement policy for human immunodeficiency virus (HIV)-infected children and children with acquired immunodeficiency syndrome (AIDS). Both policy and specific procedures are based on nationally promulgated guidelines. School placement policy is part of an overall AIDS policy that includes education of students and staff and adoption of universal precautions to prevent transmission of communicable diseases in school. Implementation has been marked by excellent collaboration between the departments of health and education. Important policy components include expedited clinical investigation of each case, an interagency review panel, strict protection of confidentiality, a restricted setting for certain children, a school site visit for each placement, and continued monitoring of the school placement by school nurses. Many HIV-infected students need special educational services and/or school health services. The Baltimore City school placement process has avoided the exaggerated publicity endured by some communities, where media reporting has aggravated community fears and invaded the lives of families with HIV-infected children. Baltimore City has succeeded in ensuring access to education, protecting families' confidentiality, and providing special care for HIV-infected students. Local communities should emphasize national guidelines in designing school placement policies for HIV-infected children. School placement policies work best in the context of a comprehensive policy incorporating AIDS education and care.

Public health policy paradoxes: science and politics in the Rockefeller Foundation's hookworm campaign in Mexico in the 1920s.

The origins of US international health endeavors are intertwined with the Progressive Era's faith in science as arbiter of humankind's secular problems. No agency better exemplifies the period's confidence in science than the Rockefeller Foundation's International Health Board (IHB), which set out to export the new public health theory and practice around the world. An examination of the IHB's hookworm program in Mexico in the 1920s demonstrates that, notwithstanding the Rockefeller Foundation's (RF) self-conscious commitment to scientific neutrality, its programs continuously engaged political criteria, exhibiting the competition, coexistence, and inseparability of the worlds of science, politics, and international health policy. Analysis of the program's quotidian decisions and larger strategies further reveals the protean quality of RF science-politics, which enabled responses to parochial and broadly-conceived needs at multiple levels. In the focus on hookworm, the selection of campaign sites, hookworm diagnosis methods, treatment procedures, definition of cure, and the assignment of responsibility for prevention, scientific and political considerations were inextricably bound. The science-politics paradox was molded by the hookworm program's constituencies in Mexico, including political leaders, health bureaucrats, physicians, business interests, public health workers, peasants, and Rockefeller officers. The multiple, often contradictory, roles of the RF's hookworm campaign are characteristic of the policy paradoxes that emerge when science is summoned to drive policy. In Mexico the campaign served as a policy cauldron through which new knowledge could be demonstrated applicable to social and political problems on many levels. The repeated pledge of scientific neutrality belied the hookworm program's inherent aim of persuading government officials, the medical community, business interests, and the populace of the value of investing in public health as a means to improve social conditions, further a medical model of health and sickness, increase economic productivity, and promote good relations between the US and Mexico.

Federalist flirtations: the politics and execution of health services decentralization for the uninsured population in Mexico, 1985-1995.

Around the world health services delivery systems are undergoing decentralization, responding to pressure to increase equity, efficiency, participation, intersectoral collaboration and accountability. This study examines the Mexican health decentralization efforts of the past decade to discern the motivations for the reform, the context for its implementation, the politics of its downfall, and the reform's impact at subnational levels of government. Sparked by economic crisis and pressure from international creditors for fiscal reform; demands for greater democracy, equity, and quality; and technocratic impulses to rationalize health services delivery, the decentralization reform could not overcome the authoritarian centralism of the federal government and its corporatist clients. In the end, even in the most technically capable states, the reform was unable to overcome political obstacles to decentralizing fiscal power, redistributing resources in an equitable fashion, and eliminating the inefficiencies of separate but unequal health systems for social security recipients and the uninsured population.

Eradication, control or neither? Hookworm vs malaria strategies and Rockefeller Public Health in Mexico.

Malaria's epidemiological importance in Mexico greatly exceeded that of hookworm, but the Rockefeller Foundation (RF) paid far more attention to hookworm. Although the RF collaborated with malaria campaigns around the world, malaria was only incidental to the RF's activities in Mexico. The hookworm campaign, on the other hand, involved the RF at every stage, from conceptualization and design to financing, hiring, and day-to-day administration. This paper seeks to understand why the RF's involvement in Mexico differed for the two diseases and what the organizational, political, and health implications were for these divergent approaches. Beginning in the mid 1920s the Mexican government developed a modest anti-larval service, periodically draining and filling ditches and swamps, dusting Paris green, petrolizing stagnant water, and administering quinine. Following the RF's 1927 shift towards scientific investigation, it began to sponsor small-scale malaria research, collecting climatological, entomological, epidemiological, and clinical information. The Mexican government eagerly petitioned the RF to join a national effort, but it was reluctant to become involved. A National Malaria Campaign was established in 1935 under President Lázaro Cárdenas to coordinate education, sanitary engineering, and treatment. The popular Campaign followed RF strategies even without its direct participation. Meanwhile, the RF avidly pursued modest malaria research in Mexico, funding U.S. investigators to conduct experiments on pesticides, mosquito-trapping, and controversially, watering methods for rice. These efforts culminated in the world's first field trial of DDT against louse-borne typhus and later as a residual spray for malaria. In the end the RF used Mexico as a convenient locale for scientific research that had global implications but only an incidental relationship to Mexico's own Malaria Campaign. Likewise, the RF's much more active hookworm program was more a means than an end, leading not to eradication of the disease, but to Mexico's commitment to modern public health organization and methods.

Malaria and social movements in Mexico: the last 60 years.

The Mexican Ministry of Health's anti-malaria campaigns of the last sixty years have overlapped and interacted with both the World Health Organization's Global Eradication Program and a series of major political, social, and demographic movements in Mexico, including economic transformation, migration, urbanization, tourism, rural development, and the building of social and sanitary services. The authors argue that three decades of successful environmentally-oriented malaria work that integrated social and economic development was followed by the Global Campaign's insecticide-based approach that failed in both its economic and public health objectives, ultimately serving to block development efforts, particularly in poorer and southern states.

To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s.

Since 1990, health services decentralization in Nicaragua has been accompanied by structural adjustment, resulting in reduced equity and accountability. Sandinista efforts in the 1980s to extend access to primary care and reduce class and regional disparities in the delivery of health services were accompanied by modest attempts to increase local-level accountability and responsiveness. The escalation of war in the late 1980s transformed this effort into greater de facto decentralization. Over the past decade, Nicaragua has used decentralization policy to restructure the health system through health spending cuts and the favoring of curative over preventive services; privatization and the promotion of user fees; and confusion of lines of accountability. The authors analyze the 1990s' health policies in Nicaragua, paying particular attention to the blending of decentralization policy with the fiscal and administrative reforms advanced by the International Monetary Fund, World Bank, and other international agencies. They conclude that analyzing decentralization as a sector-specific reform that can be ameliorated through technocratic modifications is insufficient. A full understanding of the problems and possibilities of decentralization requires an analysis of the political and economic context that conditions these policies.

Pediatric AIDS in the United States: epidemiological reality versus government policy.

Pediatric AIDS cases constitute approximately 2 percent of total AIDS cases in the United States, but HIV infection and AIDS among children pose a growing concern. Government policies have failed to match the epidemiological reality of the disease. The powerful shapers of public opinion have dedicated their energies to a handful of cases, involving the school attendance of primarily middle-class children. Unfortunately, coverage of school placement issues has overshadowed both the demographically more serious issue of perinatally transmitted AIDS cases and the growing concern over adolescent AIDS. Seventy-five percent of perinatal AIDS sufferers are poor, urban minorities: the disease is clearly related to other indicators of poor child health--urban poverty and oppressive social conditions. School-based prevention efforts for adolescents have been rendered impotent because of moralistic obstacles to explicit education. Prevention of perinatal and adolescent HIV transmission must be both sensitive and relevant to communities in which the greatest threat to survival is poverty, not AIDS. Ultimately, issues surrounding pediatric AIDS only reinforce the long-term position of child health advocates: the best investment a society can make is a sincere commitment of resources to improve the health, education, and welfare of its children.

Six seconds per eyelid: the medical inspection of immigrants at Ellis Island 1892-1914.

Beginning in 1892, immigrants to the United States were subject to a medical inspection, created to restrict the entry of persons with a"loathsome or dangerous contagious" disease or mental defficiency. Ellis Island, which received over 10 million newcomers between 1900 and 1914, served as the largest ever medical screening facility. Far from reflecting a unified policy, the medical inspection offered a complicated compromise amidst a swirl of competing interests. Many industrialists blamed the waves of Southern and Eastern European immigrants for urban joblessness, filth, unrest, overcrowding, and disease. In an era of depression, labor groups opposed immigrant competitors for scarce jobs. Nativists believed immigrants could not overcome their defects because these were genetically transmitted. Germ theory proponents recognized communication of microorganisms as the problem, with controlling the spread of infections as the solution. Many Progressive reformers held that the scientific screening of immigrants offered a systematic solution for the disorder. Dozens of immigrant aid societies struggled to attenuate the effects of the inspection, and as depression subsided after 1900, employers, too, favored the influx of immigrants. This paper examines the social and political basis for the inspection, its realization at Ellis Island, and the reasons for its inability to debar large numbers of immigrants.

Skirting the issue: women and international health in historical perspective.

Over the last decades women have become central to international health efforts, but most international health agencies continue to focus narrowly on the maternal and reproductive aspects of women's health. This article explores the origins of this paradigm as demonstrated in the emergence of women's health in the Rockefeller Foundation's public health programs in Mexico in the 1920s and 1930s. These efforts bore a significant reproductive imprint; women dispensed and received services oriented to maternal and childbearing roles. Women's health and social advocacy movements in Mexico and the United States partially shaped this interest. Even more important, the emphasis on women in the Rockefeller programs proved an expedient approach to the Foundation's underlying goals: promoting bacteriologically based public health to the government, medical personnel, business interests, and peasants; helping legitimize the Mexican state; and transforming Mexico into a good political and commercial neighbor. The article concludes by showing the limits to the maternal and reproductive health model currently advocated by most donor agencies, which continue to skirt--or sidestep--major concerns that are integral to the health of women.

Estimates of public costs for teenage childbearing in Baltimore City in FY 1987.

In 1987 Baltimore City spent about $179,500,000 on AFDC, Medicaid, and food stamps for families that were begun when the mother was a teenager. Had all these births been delayed until the mother was at least 20 years old, Baltimore would have saved almost $72,000,000 in public outlays.