INTERNATIONAL HEALTH VORK IN THE AMERICAS
       Dr. Fred L, Soper
      NATIONAL HEALTH ASSEMBLY
         May 3, 1948

  It is appropriate that this National Health Assembly;oalled for the purpose of
planning a long term health program for the United States, give attention to plans
for internmional health work,  The development of rapid air transportation has
largely outmoded traditional methods for preventing the importation of communicable
disease, Leaders in the international health field today concede that border and
port quarantine must be replabed by a general direot attaok on communicable dis-
eases in their endemio haunts.  Suoh an attaok can be oriented and aided by a co-
operative international  or anisation'without any loss of sovereignty * by the in-
feoted nation, By joining P n suah organizations, a nation not only strengthens
others but protects itself,

  The United States of America, as a world power, has a large stake in world
health and especially in Pan American health.  During IVorld Pu`ar II, the United
States learned, through its soldiers, that malaria, epidemio jaundice, tsutsuga-
mushi'disease, filariaaia and even the venereal diseases of:distant parts of the
morld, are of dire& interest to it.  Should war come again, the United States will
need healthy nations as allies, able to produoe and to fight for the common inter-
est.  Those familiar with the situation in Latin Amerioa realite that a firm basis
for prosperity oan be established only as improved health results in inoreased pro-
duoti on.

  As Dire&or of the Pan Amerioan Sanitary Bureau, the relatively unknown sister
of the Pan Amerioan Union, I welcome an opportunity of giving to this group of
leaders from many parts of the United States part of the story of international
health work in the Amerioas.  in doing so, although a number of other orghnisations
have participated, I shall refer only to the Pan Amerioan Sanitary Bureau, the of-
fioial inter-Amerioan health organieation of the 21 American Republics; to the
Rookefeller Foundation, a-private philanthropio institution; and to the Institute'
of Inter-Amerioan Affairs, an agenoy of the State Department of the United States.

.

   You are all familiar with the Pan Amerioan Union and with the International
Conferencesof Amerioan States, the Ninth of whioh in Bogota has just ended. Like-
wise you are all familiar with the T:lorld Health Organization and have noted the re-
action in this country to the announcement that the United States might not ratify
its Charter before the First'Assembly in June 1948.  But a few of you know of the
Pan American Sanitary Bureau, the dean of all international health organizations,
created in 1902, nor of the twelve Pan American' Sanitary Conferences which have
been responsible for the poliaies of the Bureau.  The Bureau and the Conferences
now operate under the Pan American Sanitary Code of 1924, a treaty which has been
ratified by all twentyone of the American Republics.  (Only in the field of health
has there been suoh unanimity among the Amerioan nations, the Code being the only
inter-American treaty to be ratified by all.) The terms of this Code and of the
Constitution adopted in 1947 are such as to faoilitate a future relationship of the
Pan American Sanitary Bureau to the oountriee of the Western Hemisphere similar to
that of the United States Public Eealth Service to the Health Departments of indi-
vidual states,  Altheugh eaoh state has its own department responsible for the
health of its people , the United States Publio Health Servioe has found ways of o
making most important oontributions to the health of the nation, In the ssme'wsy,
although eaoh of the benty-one Amerioan nationa has its health organization, there
is an urgent need for the ooordiaation of health aotfvitiee throughout the oonti-' '
nent whioh the Bureau oannot now attempt beaauee of inadequate finanoing and in-,
euffioient 8taffr


-2-

  When the Pan Ameiioan Sanitary Bureau was formed in 1902, the prinoipal stimu-
lus to the development of international health work was the desire of eaoh country
to protect its own population from imported'pestilence with a minimum of interrup-
tion to its commeroe.  It was natural, then, that the funotion of the Pan American ,
Sanitary Bureau in its early years should have been limited to the oollection and
dissemiha^,ion of information regarding the distribution of dangerous communicable
diseaie, for the purpose of imposing indioated, and avoiding unneoessary, quaran-
tines.

  The oreation of the Rookefeller Foundation in 1913 with the declared purpose
of "promoting the well-being of mankind throughout the world", resulted in B radi-
cal ohange in the approach to the solution of international health problems.  The
avowed purpose of its Yellow Fever Commission was the eradication of yellow fever
from the Western Hemisphere,  Plans for suoh eradioation involved making surveys to
determine the distribution of yellow fever followed by aotive oollaboration with
the authorities of those countries where the disease existed,

.

  By 1947, when the present Constitution of the Pan American Sanitary Organica-
tion was adopted, the general uonoept of the functions of international health
organieations had come to resemble greatly the general purpose of the Rookefeller
Foundation.  This oonatitution deolares that the fundamental purposes of the Organ-
ization "shall be'to ooordinate efforts of the oountries of ths Teatern Hemisphere
to combat disease, lengthen life and prompte the phyaioel and mental health of the
people."

   Among the most potent faotors whioh have led the Amerioan nations to accept
the broadened ooncept of international health work are the long-continued collabo-
ration of the Pan American Sanitary Bureau and of the International Health Division
of the Rookefeller Foundation in the solution of administrative health problems and
in the training of teohnioal personnel.  Time does not' permit even a summary of the
many signifioant aotivities of these two organizations, but one oannot pass over
without oomment the work of the Bureau in bubonio plague and of the Foundation in
yellow fever.  These two progrsme are important exsmples of the value of interna-
tional health work.

   Some years after the Rookefeller Fo6ndation took the responsibility for col-
laboration in the attaok on yellow fever, the Bureau undertook the solution of the
problem of bubonio plague.  Dr: John D. Long, a veteran of plague campaigns in
California and the Philippines, oame to South America during the 19209s.  From ttlm
beginning, Dr.Long took speoial interest in the plague problem and has stimulated
or carried out studies and campaigns in many oountriea of South America.  These
studies have shown'that the piature of plague in South America is not a simple one,
involving only man, the domest-lo rat and the flea, but varies widely from region to
region.  It has also been shown that plague can be imported on rat-free ships in
the bodies of infected fleas baled up in jute bags ooming from India, The orusede
had many disappointments before the stigma of plague infeotion was removed from the
records of the lest of the Amerioan ports.  A full decade has now passed sinoe
plague has been found in Guayaquil, but the struggle still oontinuea in the interi-
or of several countries.  Studies are continuing in the hope that a satisfaotory
means of eliminating plague from rural and forest areas at a reasonable ooat will .
be found,  The aohievement of the Bureau in plague has been an outstanding pieoe
of work, often oarried out under diffioultiee and always with inadequate personnel
and funde,

  Although the Rookefeller Foundation $8 a private philanthropio institution,it
hao funotioned over many years as a truly International organieation with referenoe


to the yellow fever problsm.  The Foundation undertook eradication of yellow fever
from the Amerioas in the belief that this goal could be attained within a few
years.  On the basis of previous observation, it was believed that yellow fever
would rapidly disappear from regions in whioh anti-mosquito oampaigns were oarried
out in the principal oities,  The Foundation undertook to oollaborate technically
and financ+lly in the organization of auoh anti-mosquito campaigns in those region8
where yellow fever waa known to be present.  Under this ptogrsm, yellow fever dis-
appeared promptly from the Paoifio Coast of South Amerioa, from Mexioo and from
Central Ameriob and has not reappeared in these areas during the past twenty-five
yeare. By 1926, it was believed that yellow fever in the Amerioae was limited to
northeast Brazil and that the end of the disease on this oontinent was in sight.
In antioipation of repeating'in Africa the expeoted viotory and making the world
forever free of yellow fever, the Foundation split its yellow fever staff to begin
the momentous studies in Nigeria which resulted in the isolation of the virus of
yellow fever in monkeys, the first step leading ten years later to the development
of a satisfaotory vaooine for yellow fever,

  But yellow fever did not diaappear from the Amerioas,unexplaineble outbreaks
oaourring in Rio de Janeiro in 1928, in Colombia and Venezuela in 1929, and in Bo-
livia in 1932,  These outbreaks were not in harmony with the aocepted epidemiology
of yellow fever and were understood only after it was demonstrated that yellow
fever is basioally an animal disease involving from time to time the forest are&
of all of the oountriee of South Amerioa with the exoeption of Uruguay and Chile.
This jungle infeotion is a permanent souroe of virus for re-initiating urban in-
feotions.

  In the investigation of yellow fever and in the'proteotion of exposed popula-
tions through vaccination and anti-mosquito measures, the Roolcefeller Foundation
has oollaborated in one way or another with the health authorities of all the po-
litioal units of Latin America. In this oollaboration, teohnioal personnel of one
nationality has repeatedly served in administrative and techniaal oapaaities in
countries other then their own.  The major part of funds for the yellow fever
program has oome from the govermenta conoerned, all expenditures of the Foundation
in over thirty years being less than eight million dollars.

  Although the disoovery of jungle yellow fever as a permanent sourae of rein-
feotion showed that the program for the eradioation of yellow fever from the
Americas had been impossible from the beginning, the demonstration that complete
speoiee eradioation of the urban veotor, the AEdes aegypti mosquito is feasible,
hae'led to a program for the oomplete eradioation of this mosquito from the Ameri- .'
oas, which will make the reourrence of the urban yellow fever of history impossible,
                   o                                                             ?           ?
  Between 1933, when the first looal apecries eradioation was observed, and 1940,
when the Rookefeller Foundation disaontinued its'oollaboration with the Brazilian .
Government in the oampaign against Agdes aegypti, the oity of Rio de Janeiro and
six of the Braeilian states were frwmosquito.  The Program has been oon-
tinued during the last eight years by the Brazilian Government, with the result that
praotically all of Brazil, exoepting a relatively small area in the northeast, is
free of aegypti.

  In 1947, the Directing Counoil of the Pan Amerioan Sanitary Organization ao-
cepted a proposal made by B&i1 that'a oontinental osmpaign for the eradication of
Aiides spti be 6arried out.  Brazil, which has frontiers with ten politioel units
and many seaports, might well afford to help finance eradioation programs in sur-
rounding oountriee to avoid the permanent expense of maintaining'oontrol servioea
within its cm borders to guard against infestations from abroad. Here we have a


striking example of a nation's inability to protsot itself in health matters 8x1
cept through international oollaboration.

  The resolution making the Pan Amerioan Sanitary Bureau responsible for ooordi-
nating the aotivitiee of the Amerioan nation8 in the eradication of Agdes aegypti
on a oontinent-wide basie mark8 a step in publio health philosophy a-as
the imporCanoe of whioh oannot be overetated.  Certain aountries of the Amerioaa
have be&n free of yellow fever for 60 long that they have lost all fear of this
disease, but after full diaouseion all reoognited the right of Brazil anl of Boli-
via, whioh ha6 been free of aegypti for a number of year8 now, to insilst that they
be proteoted from reinfestation by the eradioation of thie mosquito in neighboring
oountriee,  Initial steps have been taken to activate the program of eradication
in all of the South Aaaerioan oountriea and only laok of funds ie now preventing
extension of Botivitiee to the Caribbean and Central Amerioan area.  Of oourse the
United States, mhioh ie thought to present the moot diffioult problem of all, will
be left to the last.

  It is interesting to speoulate on how long it will be before tks United Statee,
taking advantage of modern means of rendering oases of venereal disease8 non-infect-
ible, Sill eradioate these diseases from this country and in the same way a8 has
Braeil, propose for its own protection a oontinental program of eradication.

  The knowledge that the aegypti mosquito could be eradicated was, in 1938, an
important factor influenoing~cision to undertake the eradication of Anophe-
les gambiae from Northeast Brazil, News of the truly disastrous epidemic omria
Gsmhi.8 African mosquito in the State of Ceara had alarmed the health work-
ers of all American nation8 since this mosquito any place on the continent repre-
sented a potential threat to all oountries.  At the time plans were being made by
the Brazilian Government and the Rookefeller Foundation for the eradication oam-
paign, it was gratifying to reoeive tentative offer8 of financial assistance from
representative6 of three other Amerioan nation8 should available resources prove to
be inadequate.  These offers were a olear indioation that Brazil's neighbor8 pre-
ferred to fight this inseot enemy outside their own borders.

  The suooess of the campaign for the eradication of Anopheles gambiae in Brazil
was of importance not only to the people of Northeast Brazil but a-the Allied
cause during World Tar II when the United State8 found it neoessary to develop a
military air-route'to Afrioa and the Middle East through the previously infested
area.  Furthermore, in 1942, Anopheles gambiae invaded Egypt from the south, with
extension down the river to Asiut, onIy=les from Cairo,  Devastating epidem-
108 of malaria ooourred in 1942 and 1943, with tremendous 1086 of life and with a
great diminution in the produotion of food suppliee so indispensable to the war
effort.  Fortunately it was poasible, in 1944-43, for experienoed worker6 to apply
in Egypt the method8 developed in Brazil. Gambiae dieappeared within eight month6
and has not reappeared during the paet thrwa,

  Surely it must be admitted that the yellow fever program of ths Rookefeller
Foundation during the past three decades ha8 been a striking demonstration of what
oan be aooomplished by a non-religious, non-politioal, disinterested organieation,
operating in the field of international health with adequate finanoes and a care-
fully ohoeen teohnioal etaff.                   .

  Shortly after the attack on Pearl Harbor; the Council of Foreign Lliillsters of
the American State6 met in Rio de Janeiro and, among other actions taken, author-
ized bi-lateral agreements between individual government6 of the Amerioan nation6
to pool re6ourao6 for health work.  l'hthia a short time the Institute of Inter-


Amerioan bffaire was ohartered as an emergenoy war-time oorporatibn under the law6
of the State of Delaware to represent the United States in making, and oarrying
out the terms of, suoh bi-lateral agreements,  During the period 1942-1947, con-
traots wete written with all of the Latin Ameriaan Republioe exoepting Cuba and
Argentina, $nvolving the expenditure of some forty-five million dollars of United
State8 fund6 and ooneiderable amounts of money of the other oontraoting govern-
ments,

  Under these uontracts, 8peoial aooperative serviaes were organized in indi-
vidual oountries in whioh United States personnel in collabgration with the nation-
al health authorities undertook the emergenay solution bf a wide variety of local
health problems involving the organization of hospitals, health centers, school8
of nursing, programs in health education and malaria control; the oonstruotion of -
building8 for many purposes, the installation of water supplies and sewage disposal
plants and the training of personnel through epeoial local courses and through
fellowships in the United States.  At no time has the Institute taken the responsi-
bility for ooordinating the effort6 of all American oountries for the solution of
a aommon problem as have the Rookefeller Foundation and the Pan American Sanitary
Bureau with yellow fever &l plague,  Rather has it identified itself in each
country with local problems.

  Eventually the Institute was taken over by the State Department afid has been
reorganized in 1947 with a Federal oharter for a period of three years, with di-
vision6 of health, agriculture and eduoation,

  The work of the Institute in its early years was handioapped by the neoessity
of rapidly building a oontinent-wide program on five year oontraote under emergency
wartime conditions when the shortage8 in experienoed personnel and in material6
were aoute.  Even now, long-term plans are impossible beoause of the limited oharter
period.  That'the work of the Institute has been greatly appreoiated is shown by
the faot that, at the present time, the Institute ie administering a number, of pro-
jeota in several countries in whioh the finanoial oontribution of the United
States Government is very small,

  In cloeing P wi6h to leave with this group a clear picture, as I eee it, of
the present situation of the Pan American Sanitary Bureau. The Bureau has, in my
opinion, the ideal mechaniem and an unequalled opportunity for productive regional
health work,  It is authorized by the treaty of 1924 to collaborate directly with
the health authorities of each of the American Republios, and the Constitution of
1947 in turn provides for the government of the Bureau, the determination of poli-
cies and the approval of budget6 by the Directing Council, composed of technical
representative8 of each of the twenty-one American nations.

  The two moat serious difficulties the Bureau ie facing at the present time are
related to finanoea and personnel,  These two problems are especially acute, since
traditionally, quota contributions from Member Governments have been kept very low,
while the professional staff ha6 been assigned from the United States Public Health
Service,

  Adequate financing on a long term basis must be arranged before a beginning
can be made on the personnel problem, but even 60, thie problem will be difficult
to aolve~ Due to the personnel polioy juet mentioned, the Bureau is practically
without an experienoed technical staff of its own*

The first etep toward8 the eolution of the finenaial difficulties of the


Bureau v;os taken by the Directing Council in Buenos Aires last year in raising the
annual quota of !Aember States from forty cents to one dollar per thousand of popu-
lation, thus increasing the regular income of the Bureau from 8115,COO to $290,000
annUa1l.y.  Knowing that this amount uas entirely inadequate for the authorized
functions of the Bureau, but realizing that any further increase in the quota might
seem oncrcue to certain countries, the Council resolved to raise additional funds
through supplementary annual contributions based on ability to pay, to be negoti-
ated directly between the Pan Pmerican Sanitary Bureau and individual governments,
On the basis of information regarding supplementary contributions totalling at
least one million dollars which would be made by certain Latin American countries,
the Directing Council approved a budget of $1,300,000 for 1948.

  The interest in the Pan American Sanitary Bureau shown by the voluntary supple-
mentary contributions of various American Republias has been most gratifying. Defi,
nite publioity can be given at this time only to the contributions of Argentina,
Mexico and Salvador,-whiah have been reported to the Bureau by the respeative
Governments .  The Minister of Health of Argentina has publicly announced that the
annual contribution from his Government would be a million and a half pesos, amount-
ing to 8375,000 annually, in addition to the regular quota of $17,000. Mexico,
with a regular quota of $22,000, has appropriated and already forwarded this amount
together with a supplementary contribution of $200,000 for this year. Salvador has
reported a eupplementary contribution of $2,000 in addition to its regular quota of
the same amount,                 .

  It should interest each of you to know that although the United States con-
tains more than half of the population of the American Republics and is in the
forefront economically, no provision has been made for a supplementary contribu-
tion to the budget of the Bureau for the fiscal year 1949. As matters now stand,
then, the United States will be contributing $L$5,000 to a budget of $1,300,000
for the official international health organization of the Americas. It is dis-
couraging to note that at a time when the United States is making appropriations
of many millions of dollars for health work to temporary organizations, no steps
have been taken to meet the ohallenge of contributions from other American Re-
publics in the expansion of the official permanent inter-American health organ-
ization.                 .

  The United States of America has recognized its special interest in the wel-
fare of Latin America and has spent tens of millions of dollars through emergency
bilateral agreements during the past five years,
the sxpenditure of much smaller          There 14 pow an opportunityV w$tk
                             sums , to get Pan American heelth work m 4 perma-
pant brrsie, with the full collaboration of all of the other &msr$.can r&$on4,
building up the Durec)u, the United States is also working tow4H the im     Iq
Q$ 4$andardr elsewheF4, since through the Bureau
f@g* t) pattern for the beya~opent' o$ region&l. health
IWR qm-t*t                                                               `..