cycle of the disease was only fully described in 1925.⁶ The first programs to fight the disease were implemented after WWII and were based on the spraying of an insecticide, DDT, to kill the vector. During the late 1960s and early 1970s, onchocerciasis gained some visibility on the international scene as it became seen as one of the main obstacles to the development of West Africa, attracting the attention (and the funding) of the World Bank and the United States. Nevertheless, it remained a neglected tropical disease because medical treatment was inadequate (the known molecules active against the disease were toxic to humans), and the pharmaceutical industry did not invest in research to change this situation because of a lack of economic incentives (the affected population being poor and unable to pay for drugs). In 1975, the WHO set up a disease control program in Africa, the Onchocerciasis Control Program (OCP). It focused on weekly sprayings of an insecticide to kill larvae (Temephos, which replaced DDT after its ban) in eight West African countries. That same year, in 1975, the WHO also launched a Special Program for Research and Training in Tropical Diseases (TDR), which was especially needed after the failure of the global malaria eradication program in the late 1960s (cf. *infra*). The goal of the TDR Program was to incentivize pharmaceutical corporations to build capacity and do research on eight tropical diseases, including onchocerciasis.

In 1977, a scientific discovery was made that would eventually deeply transform the fight against onchocerciasis: a molecule, ivermectin, developed by the US pharmaceutical company Merck, was proven to be an efficient drug, well tolerated by humans. In 1987, Merck made the decision to donate the drug to affected populations and set up a drug donation program, the MDP, with the cooperation of the WHO. The introduction of Mectizan (the brand name of ivermectin) deeply reshaped the fight against the disease in terms of strategy and practices on the ground and in terms of the role of actors involved. The WHO especially had to adapt: it designed a new program, which better fitted the challenges of Mectizan donation and enabled WHO to take back the lead in the strategic design of the fight against the disease.

There is a long history of cooperation between public and private actors in the domain of international health since the times of imperial and colonial medicine.⁷ However, beyond mere cooperation, this chapter will show how international policies to fight river blindness were shaped through co-constitution dynamics between a public actor, the WHO, an international intergovernmental organization which, according to its founding treaty, should be ‘the leading authority in public health’, and a private one, Merck, a US pharmaceutical giant and for-profit corporation. By co-constitution dynamics, we mean, in this chapter, the process of interactions, whereby actors impact each other, become entangled/intertwined, strengthen interdependencies and influence their environment. How did a collaborative relationship between two powerful actors with distinct or even opposite, goals (public interest vs. profit) emerge? To what extent were they able to influence each other? Did the partnership have a lasting impact on the fight
against onchocerciasis and neglected tropical diseases? In particular, the chap-
ter demonstrates how cooperation between the two contributed not only
to establishing the MDP but also to creating a new model for international
health policies which was applied to several other neglected diseases in the
following years.

The MDP is still active today, but the chapter mainly focuses on the years
1975-1998, that is, from WHO's outreach to pharmaceutical companies to
fight neglected diseases, thanks to its TDR Program to the extension of the
MDP 23 years later to include the elimination of lymphatic filariasis, another
neglected tropical disease. These are the years when co-constitution dynamics
took shape and were the most salient. Not only did both actors impacted each
other (by trying to act on each other's preferences, prompting reorganizations
or the design of new programs, etc.), their increased interdependence trans-
formed the field of the fight against onchocerciasis itself. It changed it in terms
of policy content since a drug, donated for free and intended for human con-
sumption, now provided an alternative to vector control programs. During
those same years, this public/private interdependence also changed the whole
institutional set-up of the fight against onchocerciasis by creating new struc-
tures and involving new actors in the fight against the disease – experts from
the MDP, communities, NGOs, etc. However, especially in the last part of
the chapter and the conclusion, I also draw some parallels with current trends
in global politics because the case of the fight against river-blindness and the
issue of the cooperation between the WHO and Merck prefigured contempo-
rary debates on the increased participation of non-state actors (corporations,
business associations, NGOs, philanthropic foundations, etc.) in international
governmental organizations and in the design of global public policies – with,
for instance, the current Sustainable Development Goals adopted by the
United Nations in 2015 requiring ‘a global partnership’ for sustainable devel-
opment between governments, the private sector and civil society.

This chapter adopts a socio-historical approach in order to illuminate and
conceptualize bigger trends in the co-constitution of international policies,
thanks to the ‘thick description’⁸ of a single case study and the reconstitution/
tracking of institutional processes and social interactions. Methodologically,
it is based on cross-fertilization between academic literature and several pri-
mary sources. First, archive documents from the WHO archives, primary
documents from Merck (such as Annual Reports in particular), and from
the Novartis archives (a Swiss-based pharmaceutical company, where I found
material shedding light on WHO pharmaceutical companies relationships
during the TDR program). Second, interviews conducted with relevant ac-
tors (employees from Merck, the WHO, the MDP, etc. – references to the
interviewees were anonymized). Third, texts (esp. letters, articles) and mem-
oirs published by actors.

The chapter is organized chronologically, in order to describe interaction
processes, while trying to show how they created interdependencies between
Merck and the WHO, contributing to the reshaping of the fight against
onchocerciasis and, more broadly, neglected tropical diseases. The first part (1975–1987) retraces the progressive building of interdependencies between Merck and the WHO during the phase of drug development, until the decision to donate Mectizan. The second part (1987–1995) focuses on the challenges that arose from the co-involvement of Merck and the WHO in the MDP. The third part (1996–present) deals with the aftermath of what was deemed a success, with the expansion of donation programs and the institutionalization of corporate participation in international organizations (IOs). Thus, the chapter will highlight co-constitution processes between two powerful actors and their effects on their field of intervention, with emphasis on institutional forms of cooperation and the content and intensity of relationships and actions. In particular, we will see that the benefits of cooperation were not self-evident, that they had to be constructed, especially thanks to the role of a number of brokers, actors who act as ‘intermediaries between two other actors that are not directly linked’.⁹ We will interrogate the nature of the policy space that was co-constituted, which could appear a ‘para-political space’ of global policies outside of the market.¹⁰

## The progressive building of interdependencies (1975–1987)

### Fostering collaboration through network creation

In 1975, WHO, hoping to achieve a new international health order that would take into account the needs of developing countries, launched the TDR, a Special Program for Research and Training in Tropical Diseases, whose actions included, among others, the development of new collaborations with private pharmaceutical companies. It was in line with larger demands made by the Non-Aligned Movement and Third-World countries at the United Nations General Assembly in 1974 to build a ‘New International Economic Order’ that would be fair, based on equality among States, and would enable developing countries to benefit from international economic growth and social progress. TDR was co-sponsored (i.e. co-funded) by the World Bank, the United Nations Development Programme (UNDP), and then UNICEF, but WHO was the executive, and thus leading, agency. The program was hosted at the WHO headquarters in Geneva, which meant that the WHO provided administrative support, that TDR personal was recruited on WHO terms and was integrated among WHO departments, etc. TDR’s aim was, and still is, to encourage research on eight neglected tropical diseases, among which onchocerciasis/river blindness.¹¹ Treatments for these diseases were unavailable or inadequate, and the pharmaceutical industry did not exploit recent technological developments that could change this situation, arguing that economic incentives were too low. In addition, in the late 1960s, WHO had seen the failure of its flagship Malaria Eradication Program and was thus
looking for funds and seeking to develop new approaches to control diseases
affecting developing countries.

At the core of TDR's strategy lay the establishment of collaborative re-
lationships between academic institutions and pharmaceutical companies
through the creation of a network of researchers and organizations and thanks
to the use of WHO's capacities and resources.¹² Pharmaceutical corporations
could be part of the network by participating in the administrative structure
of the program: they could send their researchers to the scientific work-
ing groups that defined TDR's research directions for each of the neglected
diseases. They also had the possibility to share resources and to use shared
resources: for instance, TDR made available a network of centers to perform
clinical tests and of screening centers for compounds in order to avoid the
disuse/disregard of molecules potentially active against tropical diseases and
owned by pharmaceutical companies.¹³ TDR thus appeared to be a network
in the sense of ‘a cluster or complex of organizations connected to each other
by resource dependencies’.¹⁴

However, the creation of such a network was not easy and took place pro-
gressively. TDR had first to make pharmaceutical companies aware of the
existence of ‘resource dependencies’ among actors (meaning that the WHO,
research institutes and pharmaceutical companies possess different resources –
compounds, screening capacities, access to populations, etc. – that should be
put in common) in order to overcome the corporate unwillingness to engage
in such an initiative. To this end, a specific communication strategy, through
a system of visits of TDR/WHO people to pharmaceutical companies, was
put in place. For instance, in 1976–1977, three TDR scientists, Dr. Goodwin,
Lämmler and Duke, visited several pharmaceutical companies that had in the
past shown an interest in tropical diseases or that still maintained some min-
imal activities in this field. They informed them of the existence of screen-
ing centers that were ready to receive the compounds that pharmaceutical
companies would send them.¹⁵ Such visits aimed to promote TDR activities
and to put pressure on companies to engage in the network. According to a
Ciba-Geigy (a major Swiss pharmaceutical company) executive, M. Kuhn,
it was an opportunity for firms to ‘demonstrate goodwill’¹⁶ and to improve
relationships with the WHO, at a time when tensions had arisen between the
public health organization and private actors. Indeed, during the late 1970s,
there were conflicts between WHO and several pharmaceutical corporations
when the public health organization tried to take on a regulatory role, es-
pecially when the WHO established guidelines regarding the commerciali-
zation of breastmilk substitutes¹⁷ and published a list of ‘essential medicines’,
which determined which drugs should be bought in priority in a context of
financial constraints for national health systems.¹⁸ These conflicts took place
within a broader context of debates in the 1970s on the consequences of
decolonization and the key role the private sector had played in colonialism.
Some media coverage, especially in the press, was also effective to raise the
profile of the TDR program. For example, a Hoffman La Roche biologist, Dr. Ian Skinner, said that it was after reading a press article on TDR, that he thought it would be a good idea for his research institute to screen compounds for parasitic diseases.¹⁹

In 1981, five years after its inception, TDR connected 2300 scientists from 118 countries in a network organized around resource dependencies-based relationships.²⁰ By 1985, it managed to double the total amount of research expenditure on tropical diseases in the world.²¹ However, this network remained weakly institutionalized, and the participation of companies depended on their goodwill. They could easily either refuse to participate or get out without much cost. TDR was based on a strategy of soft influence, targeted at specific individuals from the private sector, whose advice was sought, who were asked to participate in TDR working groups, etc. It tried to influence corporate preferences indirectly, focusing on the involvement of individuals in order to act on their scientific *ethos*, thanks to the multiplication of scientific contacts, information dissemination, so that maybe, eventually, they might bring their company and its resources into the network (cf. *infra*). This is why it would be misleading to describe TDR as the ancestor of public-private partnerships (PPPs), which would develop in the 2000s as we will see in the last part of this chapter. Nevertheless, in view of the absence of other initiatives in the field of neglected tropical diseases, TDR's strategy paid off. It was especially the case with the discovery of an effective molecule against onchocerciasis/river blindness, ivermectin, and then its development by the US pharmaceutical group Merck. In 1977, TDR employees had met with staff of 16 pharmaceutical companies to assess the status of the research, but none of them worked on onchocerciasis.²² Merck was part of TDR; for instance, it used screening centers of the network,²³ but the discovery of the molecule and development of the drug would require a new phase in the Merck-WHO relationship, with new social interactions and new institutional processes.

*From ivermectin to Mectizan: highs and lows in the WHO-Merck collaboration*

Ivermectin is a broad-spectrum antiparasitic agent developed in the mid-1970s for animal use by the US firm Merck, thanks to the cooperation with a Japanese research institute, the Kitasato Institute in Tokyo, which supplied the US company with soil microorganisms. The veterinary market of industrialized countries represented a very important financial windfall for the pharmaceutical industry. But Merck researchers then discovered that the molecule was active against the *onchocerca cervicalis* parasite, which infects horses, and is very close to *onchocerca volvulus*, which infects humans and causes onchocerciasis/river blindness. They then hypothesized that ivermectin may have an effect on onchocerciasis in humans.²⁴
The Director of Merck Research Laboratories, Dr. William Campbell, and his team decided to send the promising molecule for screening to an Australian institute that was part of the TDR network. WHO's solicitation of pharmaceutical companies and the participation of Dr. William Campbell in the Scientific Task Force on Filariasis established by TDR in 1977 played a crucial role in this decision.²⁵ Because of his involvement in the Task Force, he was aware of the existence of TDR screening facilities (cf. *supra*). Dr. William Campbell was a passionate and dedicated parasitologist, and though at first, at the end of his doctoral studies in the late 1950s, he had 'considerable misgiving' about working for the pharmaceutical industry, he found there a fruitful work environment.²⁶ In the 1960s, he had already worked on developing human applications of the veterinary drug thiabendazole.²⁷ On 9 May 1977, Dr. Campbell wrote to his superiors at Merck suggesting that ivermectin might also treat human diseases.²⁸

His role in the discovery of ivermectin co-earned him the Nobel Prize in medicine in 2015, with Satoshi Ōmura a Japanese microbiologist at the Kitasato Institute in Tokyo who took the lead in isolating the microorganism that was sent to Merck. In his biographical note written for the Nobel Prize, Dr. Campbell remembers that at Merck, he became convinced that

> at least in the near term, the probability of finding a drug by empirical screening (for which there was much historical precedent) was higher than the probability of finding one through research on the biochemical processes of parasites (for which there was no precedent).²⁹

Thus, in July 1978, ivermectin was sent to a TDR screening facility in Australia. Results were positive, and the question was raised of whether Merck would pursue the development of a drug for humans.³⁰

Merck decided to move in this direction both because the financial risk for the company was low since there was a veterinary market anyway and because some researchers strongly supported the project. This was the case of Dr. Mohammed Aziz, senior director clinical research at Merck, the most knowledgeable researcher on onchocerciasis in the company because he had previously been employed by the WHO in sub-Saharan Africa, as a coordinator in Serra-Leone.³¹ Born in 1930³² in what would become Bangladesh, Dr. Aziz obtained his medical degree in Dacca, a PhD in clinical pathology in Minnesota and was also trained at the Johns Hopkins School of Hygiene and Public Health and at the London School of Hygiene and Tropical Medicine, two of the most respected public health institutions in the world.³³ He joined Merck in 1976, when research on ivermectin and onchocerciasis was rapidly developing.³⁴ Dr. Aziz took the lead in conducting clinical studies of ivermectin in West-African countries. Especially, he conducted the pilot study on ivermectin in Senegal in 1981 on 32 patients. WHO did not participate in the study, trials were fully organized and funded by Merck,³⁵ but Dr. Aziz made use of his WHO and country contacts to organize the studies.³⁶ Like
Dr. Williman C. Campbell, Dr. Aziz acted as a broker between Merck and the WHO, acting as intermediaries between the world of public health and the one of private research and development by a for-profit company. Within Merck, research on the molecule was seen as very promising. Ivermectin had an exceptional status, was described as ‘powerful’, ‘incredible’ and was the subject of a strong ‘emotional investment’, which made it difficult to stop the development process – it would have demotivated employees.³⁷

The collaboration between Merck and WHO went on smoothly until 1981, especially because it was limited to the use of TDR infrastructure. But strong tensions emerged in 1981–1982, when concertation between Merck and WHO resumed, once the first results of the study conducted by Dr. Aziz were known. These tensions ensued from a divergent appreciation of the possibilities offered by the molecule. The WHO analyzed with great caution the tests carried out in Senegal: it criticized the study for being too limited, carried out on very few patients and with a high probability of discovering significant side effects later on. Its reluctance was summarized in a letter published in the *Lancet* journal³⁸ by Dr. André Rougemont, a physician attached to the WHO OCP, which greatly minimized the progress of the compound developed by Merck.³⁹ This letter did not represent the official position of WHO, but it reiterated a number of arguments presented during a visit of WHO at Merck. The ‘lack of enthusiasm’ of the WHO was already acutely felt at that time.⁴⁰ Dr. Aziz and his colleagues responded to Dr. Rougemont in the *Lancet* a few weeks later, defending their study and its potential.⁴¹

WHO's reluctance, which may appear paradoxical at first, was due to its orientation in terms of public health, which made it very attentive to the possibilities of large-scale use of a drug. This meant that there should be very few side effects because they would become impossible to manage if they were too numerous. There was also a divergence of approach: TDR favored the search for a macrofilaricide killing the adult worm responsible for onchocerciasis, while ivermectin is a microfilaricide, killing only the larvae that cause dermatological and ocular lesions. This treatment must therefore be renewed regularly during the lifetime of the adult worm in the human body – about 15 years. Finally, it was also clear that that the WHO wanted to defend its own OCP program by legitimizing its approach to the elimination of the vector (larvae) by an action on the environment (spraying of larvicide). Merck nevertheless continued the development of ivermectin for human use and chose as commercial name Mectizan.

Starting in 1982, collaboration between WHO and the pharmaceutical group resumed under better auspices. Merck needed the WHO to conduct large-scale clinical trials, whereas the international health organization eventually became interested in a molecule whose properties seemed to be confirmed. In 1982, clinical trials were launched in Guatemala, Liberia, Ghana, Côte d'Ivoire, Mali, Senegal and Togo to determine dosage, tolerance and precise effects on disease transmission.⁴² WHO, the World Bank, TDR, Merck and OCP worked together to implement these large-scale studies. In
1986, the American corporation considered the results sufficient to request an authorization to commercialize Mectizan with the French authorities, which was granted in 1987. It was requested in France because some cases of onchocerciasis were recorded there in West-African immigrants who could participate in clinical trials. Furthermore, it was a good entry point to the Francophone West African market, where onchocerciasis was most prevalent. WHO also conducted further trials: 13 new studies were conducted by OCP and TDR between 1987 and 1989 to refine the guidelines for drug distribution and to ensure a safe widespread use.

If tensions around scientific collaboration to develop the drug had ceased (competition for research strategies had stopped, some coordination was even necessary to conduct clinical trials), the same cannot be said of the commercialization process of Mectizan. The WHO was worried about the price that Merck wanted to fix and kept stressing that it had to be low. This position was unfavorably perceived by the company, which considered that the international health organization should simply set up the distribution channels and not interfere in pricing⁴³ – a common position endorsed by all pharmaceutical corporations, supported by some governments such as the United States, especially at a time of heated debates on the issue of ‘essential medicines’ (cf. *supra*). But the issue of Mectizan commercialization took a new turn when Merck announced on 21 October 1987, right after it had obtained the French authorization to commercialize Mectizan, that it was going to give the drug ‘for free’ and to take charge of the donation by creating a specific program.

## Merck's decision to donate Mectizan in a context of interdependencies

Donation of the treatment had not been the first envisioned option. Merck tried to sell Mectizan. However, it was rapidly clear that, since affected population were poor, the price set would have to be low. The WHO strongly insisted on this: ‘any price charged for the drug should not be beyond the limited financial capabilities of the endemic countries’.⁴⁴ Furthermore, the press had made public the progress on the development of the drug in 1982⁴⁵ – a publicity facilitated by the cooperation with WHO, a public organization. As Roy Vagelos, Merck CEO, recalled:

> The *New York Times* picked up the story. The magazine section had river blindness on the cover, and the story mentioned that Merck had a drug that was almost miraculous – and what was Merck going to do with it? So the pressure was on.⁴⁶

In July 1985, Merck published a statement saying that it would ‘make appropriate arrangements’ to supply the drug.⁴⁷ Merck began to explore the option of a price at cost which would be affordable to developing countries through development aid. Merck contacted several organizations, including the US Agency for International Development (USAID) and the US Department
of State, to check whether any of them would agree to pay for the purchase of the drug and then make the donation under development assistance programs.⁴⁸ Confronted with negative answers, the possibility of giving the drug (at first for a very limited period of time) began to be studied.⁴⁹

Donations of medicines are an old tool available to pharmaceutical companies, which they use in three cases: donations known as inventories, that is, of products soon outdated or over-produced, the most frequent case; donations of products that the company commercializes otherwise for profit, and which are donated to meet the demand of an organization in the case of a humanitarian catastrophe or as part of a development program; and donations for which the company produces specifically – a rare case. The Mectizan donation fits in this latter category.⁵⁰ All these donation practices are recognized: in most countries, companies can obtain tax exemptions. In the United States, for instance, a company can deduct donations from its annual taxable income up to a maximum of 10%.

Merck was familiar with drug donations. The Merck Foundation had been managing the Merck Medical Outreach Program since 1958, which made available to selected US NGOs medicines for their humanitarian programs in developing countries. Other factors favored the option of a donation such as the absence of financial risk. The 1980s were a period of significant growth for Merck, whose sales doubled between 1985 and 1989, thanks to many ‘blockbuster drugs’ (such as the anti-inflammatory drug Vioox) and to ivermectin, marketed as a veterinary pest control product since 1981. In 1987, ivermectin was the second best-selling Merck product and contributed to the company revenue at about US$ 100 million per year, which was ‘a first for a veterinary product’.⁵¹ This context allowed managers to focus on secondary objectives such as the image of the company: ‘While Mectizan will not contribute to sales, our decision has contributed a great deal to public regard for the Company’.⁵²

However, within Merck and the pharmaceutical industry, voices worried about the precedent that it would set, which would most probably open the door to other drug donation requests. These worries were expressed in particular through the powerful American association of pharmaceutical producers, the PhRMA.⁵³ Those concerns were counterbalanced by the fact that, according to a Merck forecast, a MDP was likely to be a success: the drug was considered a ‘miracle treatment’,⁵⁴ simple to use (an annual dose is sufficient) and without known-side effects at the time (problems in regions where the disease *loa loa* is co-endemic were not yet known). Thus, it would be possible to quickly set up an effective program, it was ‘an achievable target’, which was essential because, as a former top-level employee at Merck would point out in an interview, companies are very pragmatic, and the key element in the decision to give Mectizan was this belief in the possibility of a successful program with immediate results.⁵⁵

The decision to donate the drug was the result of an internal corporate process, but it took place in a context of interdependencies. As documents
from the WHO Archives show, meetings and discussion between Merck and the WHO continued. Merck's researchers such as Dr. Campbell and Dr. Aziz, who played a key role at the beginning of Mectizan's development, were still very much engaged in the process. They attended meetings with the WHO – for instance, Drs. Campbell and Aziz attended a meeting on April 30, 1987 with WHO; Dr. Aziz was part of a working group that met in September–October 1986 to discuss the use of ivermectin by the OCP.⁵⁶

At first, some at WHO were also perplexed by the perspective of a donation. They were concerned that pharmaceutical companies, for fear of having to set up a donation program every time they made a major discovery on a tropical disease, would renounce their slight but emerging commitment to do research in this area. Moreover, the design and management of such a donation program remained a puzzle. Nevertheless, the idea of a donation took hold. Summaries of meetings between Merck and the WHO on the distribution of ivermectin in late September/early October 1987 show, for instance, that when Merck offered to make ivermectin available free of charge for two years, WHO explained this was not enough, and that five or six years would be more consistent.⁵⁷

On 21 October 1987, Roy Vagelos, Merck CEO (Chief Executive Officer), announced to the press Merck's commitment to give as much Mectizan as necessary for an unlimited period of time. This came partly as a surprise, as discussions were still ongoing with WHO, but the granting of the authorization to commercialize Mectizan by the French authorities seemed to have triggered the announcement. Named CEO of Merck two years before, in 1985, Roy Vagelos had the final authority to make these kinds of decisions. As political scientist Philip Cerny notes, the impact of the leader on the decision-making process depends on the rules that give him power and also on the capabilities of the individual: his know-how, his charisma, his ability to surround himself – what Cerny calls ‘the personal equation’.⁵⁸ A scientist and physician by training (he was a lipid biochemist and a cardiologist), Vagelos joined Merck in 1975 as Senior Vice-President for Research. He had previously worked as a scientist at the National Institute of Health in Bethesda, near Washington D.C. (one of the world’s most renowned medical research center) and then was chair of the Biochemistry Department and of the Division of Biology and Biomedical Sciences at Washington University in St. Louis, Missouri. At Merck, he was involved in the decision to continue the development of ivermectin for human use. Especially, he encouraged Dr. Campbell’s early efforts to explore the possibility of human use for ivermectin.⁵⁹ In his own words, this stance ‘reflected the fact that I was so new to the business world that I still thought of myself as a physician first, scientist second, and president of an industrial laboratory third’.⁶⁰ Thus, he was receptive to the scientific interest and arguments of the researchers working on the project. But, in 1987, when the decision to give Mectizan was taken, Vagelos found himself in a different position: ‘I would have to become a business leader and would have to rearrange my priorities: I would have to become a corporate
leader first, a medical scientist promoting innovation second, and a physician concerned about healing third'.⁶¹ This led to a new understanding of his ‘personal equation’, which made him especially sensitive to the internal need of cohesion of the company, the opportunity that the donation represented for Merck in terms of image, but also for himself. In the words of one of his collaborators, ‘the company’s image was incredibly important to Vagelos’.⁶² We may see in his actions a willingness to leave his mark, his legacy – this is reflected in the fact that he has written a lot, particularly on his philanthropic commitment, thus helping to highlight his actions at the head of Merck. He also legitimized the decision to donate Mectizan by highlighting that it was in line with the company history and the vision of George W. Merck, emblematic president of Merck from 1925 to 1950, who gave the company its motto: ‘We try never to forget that medicine is for the people. It is not for the profits. The profits follow, and if we have remembered that, they have never failed to appear’. Furthermore, as ‘a corporate leader first’, Roy Vagelos was well aware that it was important for internal reasons – the motivation and loyalty of employees – to find a way for Mectizan to be distributed. Fran Hawthorne relates that Vagelos, when asked why he made the decision to donate the drug ‘did not mention the patients suffering from river blindness. He spoke about “the people at Merck. The research people and how disappointed they would be if the drug never reached the people that would benefit”’.⁶³

Although the donation decision was ultimately made and announced by Merck CEO, it was clear that it did not stem from the vision of a providential leader, but was the result of several factors (the favorable business situation of Merck; its historical use of donations; the high cost of going backward and the risk to employee motivation; etc.), the involvement of several actors (we especially underlined the contributions of brokers such as Drs. Campbell and Aziz) and of the continued relationship with WHO. Even if the IO did not ask directly for an unlimited donation, it constrained the decision by highlighting the crucial issue of cost, the inadequacy of a short-term donation, and by cajoling Merck and emphasizing ‘the public spiritedness’ of the company and ‘its desire to do what is best for the public good’.⁶⁴ This web of interdependencies gave rise to new challenges in the organizational design of the program to distribute Mectizan. Such a cooperation for the implementation of a large-scale health program was unprecedented: the MDP can thus be seen as the forerunner of a movement of renewal in development policies, co-produced in partnership.

## The challenges of Merck and WHO's co-involvement in the Mectizan Donation Program (1987–1995)

### A difficult balance between independence and control

When Merck took the decision to donate Mectizan, executives were aware that the company could not assume the distribution of the drug on its own.
During the clinical trial phases, Merck teams had already understood the numerous obstacles to overcome to get access to affected populations.⁶⁵ Developing a large-scale donation program was going to be a challenge. In view of the established relationship with WHO over the past decade and the input the global health institution had already provided, it had to be included in the distribution program.

For Merck as for the WHO, the first necessity was to set up an institutional mechanism that guaranteed their respective independence. Neither the pharmaceutical company nor the intergovernmental organization wished to be bogged down in a program that would prove ineffective and detrimental to their image. At the same time, both organizations needed to retain control over their participation. Their constraints and demands explain the final institutional design of the MDP.

In order for Merck to get image benefits from the drug donation, the program had to have measurable outcomes and be without harmful consequences. Since risks arose mainly from the possible side effects of Mectizan, the establishment of an effective monitoring mechanism to ensure that these effects were reported and dealt with was crucial. Otherwise, they could damage the reputation of ivermectin, including on the very lucrative veterinary market. Moreover, Merck was concerned with avoiding the drug's appearance on the black market or even on the clandestine veterinary market, which meant that distribution channels had to be strictly framed.⁶⁶ In order to prevent these two outcomes, the American giant wanted to closely monitor the program. At the same time, an invasive commitment by the pharmaceutical firm could weaken its commercial position in recipient countries, for example, if a donation of Mectizan was refused to a government because of shortcomings in the distribution project. In order not to jeopardize future commercial relations, the company wanted to stay clear of the evaluation of donation requests.

WHO was also in an ambiguous position. It is an international intergovernmental organization, owned by Member-States. Though its Constitution (article 71) acknowledges that it may 'make suitable arrangements for consultation and cooperation with non-governmental international organizations', it is far from authorizing the organization to jointly lead a committee with a for-profit company – without mentioning the political controversy that would arise. The debate on how far WHO could go in institutionalizing its relationship with non-state actors, and in particular for-profit ones, would continue in the following decades, especially at the end of the 1990s, when WHO became engaged in several public-private partnerships (cf. infra). In accordance with its Constitution and previous actions, in 1987, WHO envisioned two possibilities: either to keep to an advisory role, counseling Merck and recipient countries, or to be the only final decision-making body for parties eligible for donations. However, neither of these options seemed satisfactory enough. In the first case, WHO would be confined to a secondary role; in the second one, it would be the only one to face critics and bear
responsibility in case of a problem with a donation (and it was not sure Merck would accept such a solution anyway). Thus, WHO proposed an alternative: a tripartite consultation mechanism between Merck, WHO and governments of recipient countries.⁶⁷ But Merck rejected a process that would involve the company directly and came up with a counter-proposal: a committee of independent experts that would neither be under the jurisdiction of the WHO nor of the pharmaceutical group.

In order to set up this independent committee, the US company contacted an organization specialized in the management of health programs, the Task Force for Child Survival. It was established in 1984 by WHO, UNICEF, the World Bank, UNDP and the Rockefeller Foundation to revitalize the Expanded Program on Immunization, which had been tasked since 1974 with vaccinating all children against diphtheria, tetanus, tuberculosis, pertussis, poliomyelitis and measles.⁶⁸ The use of the Task Force for Child Survival, an experienced actor in the health field, although on a different issue, to take over the management of the MDP, reflected both the importance of networks in global health and the Task Force's desire to expand its visibility within the international health community. The Director of the Task Force, Dr. William Foege, was the former Director of the Center for Disease Control in the United States and a well-known and respected personality. The enlargement strategy of the Task Force would eventually lead to a name change (it subsequently became the Task Force for Global Health) and a broader reach. The organization is now involved in various health programs and manages several public-private partnerships.

The Task Force, located in Georgia (USA), has hosted the Secretariat of the MDP since its inception. It has acted as a third-party, an intermediary, between all parties to the donation program (Merck, WHO, the Mectizan Expert Committee, recipient countries). The Mectizan Expert Committee (MEC) has been the other central organ of the MDP, the decision-making body that meets once or twice per year to evaluate applications from organizations wishing to distribute Mectizan. Organizations authorized to distribute it (NGOs, foundations, health ministries, WHO's OCP program, etc.) take a commitment for a minimum period of five years. An annual evaluation authorizes them to continue distribution or not.⁶⁹

From the very beginning, the independence of the MEC was very important for all stakeholders, as it guaranteed the credibility and smooth running of the donation program.⁷⁰ Nevertheless, even if Merck made a point of not intervening in the committee's deliberations and even if the MDP secretariat functioned independently from the pharmaceutical company, the latter maintained significant control over the MDP structure.

## Merck's control mechanisms

The MEC was composed of seven experts, recognized as public health specialists. They should not be employed by Merck during their three-year term
on the MEC, but they are appointed by the US group upon recommendation from the WHO and the Task Force for Global Health.⁷¹ The MEC also includes three non-voting members representing Merck, WHO and the Centers for Disease Control and Prevention. The pharmaceutical group financed the administrative functioning of the committee, especially personnel costs – the main task of the staff is to prepare the files of donation requests to be evaluated by MEC members.⁷² Members of the expert committee receive a daily allowance during the sessions, and their transport and accommodation costs are covered by Merck. The company also regularly conducts audits to assess the committee’s activity.

The MEC evaluates applications submitted by organizations wishing to distribute Mectizan and makes the decision whether or not to accept them. But other actors intervene in the donation decision and in the distribution processes. The MDP secretariat, that is, staff members of the Task Force for Global Health, carries out field work: information gathering, verification of data provided by organizations, coordination with WHO, verification of the distribution process, etc. The final distribution to patients is provided by recipient organizations: NGOs, foundations, health ministries, etc. However, Merck remains fully in charge of the delivery of medicines, a key step in the Mectizan distribution chain. Once the MEC has selected recipient organizations and the quantities of Mectizan to be supplied, these data are transmitted to Merck Corporate Contributions, which triggers the shipment of the drug from the pharmaceutical group’s export department in Riom (France).⁷³ Merck Corporate Contributions monitors the process until the Mectizan has arrived at its destination. The firm manages this step unilaterally, despite demands in the 1990s that Mectizan be stored in recipient countries in order to give local organizations and governments more room to maneuver, especially to decide on the precise timing of drug distribution.⁷⁴

National governments were sometimes worried about a distribution program that bypasses their structures and over which they have no control. The control of organizations authorized to distribute Mectizan was a frequent source of concern. Health ministries, in particular, would like to take care of storage and supervise the delivery to NGOs. The Ministry of Health of Sierra Leone, for instance, requested to be informed, through Merck Director of Operations in Africa, of any treatment request made to the MDP.⁷⁵ This is why, in 1989, the MEC issued new guidelines for the submission of donation requests: except in the case of the OCP (WHO’s program), all applications now had to be approved by the Ministry of Health of the country where the donation would take place.⁷⁶ Nevertheless, Merck continued to supply Mectizan directly to the applicant organization and not to the health ministries. The company’s goal was to accommodate some of the governments’ wishes to monitor the donation without losing control of its program.

Merck also closely oversees scientific surveillance of Mectizan and the analysis of medical data collected in the field. In the early 1990s, severe and sometimes lethal side effects were observed in the case of a co-infection of
onchocerciasis with loa loa, a rare parasitic disease. Since 1995, guidelines have been developed to identify populations affected by loa loa in central and western Africa, and the MEC takes this new criterion into account in the allocation of donations.

## WHO takes back the strategic lead

The role of WHO is mainly to provide advice and expertise to the MDP. It produces data and analysis, is regularly consulted by the Task Force for Global Health, and assists organizations and countries wishing to apply for a donation. It may also be a candidate for a donation through its OCP. The role of the OCP was greatly affected by the creation of the MDP, which took the forefront in the fight against onchocerciasis and forced the program to redesign its operations. The OCP expressed a wish to play a coordinating and centralizing role in the distribution of Mectizan. It suggested, for instance, that Mectizan donations to NGOs transit through its structures, which Merck refused.⁷⁷

But from the mid-1990s onward, the WHO developed a new health strategy that transformed the distribution of Mectizan, forcing the pharmaceutical company to adapt. This strategy allowed WHO to reclaim a concept – the donation program – which it did not initiate and to re-take the lead in the fight against onchocerciasis. Until then, the distribution model was based on mobile teams, made up of professional health workers. In 1995, WHO proposed that Mectizan distribution would now be carried out through community-based programs, in line with a more general trend in development policies which aimed at involving local actors. This implied the strengthening of local health systems and the training of local health workers. With this approach, the WHO reverted to the primary health care principles of the Alma Ata Declaration of 1978.⁷⁸ This role of communities was possible because the drug is easy to use, relatively safe, and can therefore be administered with ‘minimal supervision’.⁷⁹ The aim was also to make the distribution of Mectizan sustainable by reducing the costs and extending coverage since the drug must be distributed once or twice a year for 15 years and mobile teams were expensive and did not cover large areas.

Merck was far from delighted by this change of approach, which saw the distribution of Mectizan entrusted to non-medical personnel selected by communities.⁸⁰ It was a departure from the traditional interlocutors of the pharmaceutical industry (physicians, nurses, health ministries, etc.) with which companies were used to interact and which were potential contacts for the distribution of other treatments. This new orientation promoted by WHO was part of a movement to strengthen the role of national actors in development aid policies and to increase the involvement of populations so that they were not only passive recipients. Merck finally decided to support this community-based approach for several reasons. First, Mectizan had proven to be extremely safe (except in the case of co-infection with loa loa), very
simple to administer, and WHO offered to put in place training programs for
workers chosen by the communities. Second, MEC members supported this
approach. Merck could not afford to undermine the authority of the commit-
tee because its independence was the cornerstone of the MDP. Finally, Merck
realized that without this change in distribution procedures, the program
might not be sustainable over time or expand – and the change in approach
actually doubled coverage. WHO launched a new program, the African Pro-
gram for Onchocerciasis Control (APOC), established in 1995 in 19 African
countries, to implement this ‘community-directed treatment’ strategy. One
of the main architects of APOC was Dr. Uche Amazigo. A Nigerian biologist
trained in public health, she had been collaborating with the TDR Program
since 1978 and she was a firm believer in the necessity of working with com-
munities.⁸¹ This program connected old and new actors of onchocerciasis
control to ensure ivermectin distribution for several years. Ultimately, WHO
succeeded in re-taking the upper hand by a recourse to its normative role (the
design of health policies) as a public actor, beyond the mere assistance role
that the OCP had been relegated to.

In the post-development phase of Mectizan, cooperation between Merck
and the WHO continued to ensure distribution of the drug and gave rise
to more sustained and institutionalized interactions as the MDP was estab-
lished. Its creation was the combination of each actor's preferences to pre-
serve their interests and/or mandate and of their interactions (e.g., when a
compromise had to be reached when Merck refused to take responsibility for
selecting recipient organizations). The set-up of the MDP modified the role
of WHO's OCP, which became a recipient of donations, but WHO was able
to ultimately reshape the donation program by proposing a new 'community-
directed treatment' strategy in line with its general primary healthcare policy.
The field of the fight against onchocerciasis was deeply transformed by the
MDP. In terms of content, a further change in strategy took place: a drug,
which replaced vector control programs, was donated through specific chan-
nels. In terms of institutional shape, new structures were created (such as the
MDP and APOC) and new actors were now involved in the fight against the
disease (such as experts, communities, NGOs and the Task Force).

The aftermath of a successful program (1996-present)

*A lasting impact on the fight against neglected tropical diseases: the expansion of donation programs*

From the beginning, the MDP was considered a success. It brought Merck
not only benefits in terms of image and reputation, including in the business
world, as the *Fortune* magazine 'most-admired business' award shows, but it
also gained a very good integration within public health networks, regular
contacts with the WHO and a certain familiarity with the Task Force and
NGOs involved in onchocerciasis control. The company thus significantly
improved its status in global health. Moreover, in terms of scientific fame, Dr. W.C. Campbell's role in the discovery of ivermectin co-earned him the Nobel Prize in medicine in 2015 (with Dr. Satuchi Omura of the Japan-based Kitasano Institute who took the lead in isolating the microorganism). As for the WHO, it was able to revamp the fight against tropical diseases affecting poor population which had stalled since the 1960s and the failure of malaria eradication. The development of Mectizan can also be seen as a success for WHO's TDR program and the distribution of the drug emphasized WHO's capacity to build programs and design strategies. The intergovernmental organization also gained experience in cooperating with non-state actors.

This success led to an expansion of the MDP. In 1997, it was discovered that the combination of two molecules, albendazole and ivermectin, was effective in fighting lymphatic filariasis (also known as elephantiasis), a parasitic disease that affects 120 million people in regions where onchocerciasis is also present. Merck was ready to expand the donation of Mectizan to include treatment of lymphatic filariasis. WHO contacted the producer of albendazole, the British pharmaceutical company SmithKline Beecham (now GSK), which agreed in 1998 to give the molecule. Like ivermectin, albendazole is an antiparasitic drug originally developed for the veterinary market. The joint donation of Mectizan and albendazole is complex to implement, as the two drugs are to be distributed at the same time, but following different company procedures. The donation of albendazole by GSK is made through WHO and its Global Program for the Eradication of Lymphatic Filariasis, which also coordinates the delivery of the two drugs.

Following the success of Mectizan, new donation programs were created in the following decades. One example is the donation of Zithromax by the US pharma giant Pfizer to fight trachoma, an ocular infection caused by a bacterium (Chlamydia trachomatis) transmitted by flies or human contact. It can lead to blindness and affects 41 million people worldwide. The donation initiative came from the American foundation Edna McConnell Clark. It had a research program on tropical diseases, in particular, schistosomiasis, onchocerciasis and trachoma, for which it collaborated with the WHO and TDR. The Clark foundation convinced Pfizer that a donation on the model of Mectizan would be in its interest.⁸² In 1998, the Zithromax Donation Program was institutionalized through the formation of the International Trachoma Initiative, whose mechanisms closely resemble those of the MDP (with the establishment of a Trachoma Expert Committee, for example). In 2009, the Task Force for Global Health also took over the management of the International Trachoma Initiative, in line with the expansion of the Task Force's portfolio. But other donation programs followed a different organizational model. For instance, in 1989, Ciba-Geigy launched a leprosy control program in India. The company gives the necessary treatment, but it is an 'in-house' program, managed by its foundation.

Many saw the Mectizan donation as a program that 'awakened' other companies, opening their eyes to the opportunities offered by donations in terms
of reputations and contacts in global health.⁸³ Nevertheless, it took more than a decade for cooperative donation programs to multiply, and the initiative to create them stemmed mainly from private foundations, such as in the case of the Zithromax donation, or from the WHO, which embraced donations as a way to fight neglected tropical diseases. On top of the Mectizan, albendazole and Zithromax donations already mentioned, the WHO is involved in a Novartis donation against leprosy (1999), a GSK donation against malaria (1999), a Sanofi and Bayer drug donation against African trypanosomiasis (2001), a Bayer donation against Chagas disease (2004), a GSK and Johnson&-Johnson donation against helminthiases (2005), a Merck KGaA (a German company, not the American Merck&Co.) donation against schistosomiasis (2007), a Novartis donation against fasciolosis (2007), a GILEAD donation against leishmaniosis (2012), an Eisai Co. donation against lymphatic filariasis (2013) and a new EMS (a Brazilian firm) donation against yaws (2018).⁸⁴ These donations did not necessarily lead to the establishment of programs as institutionalized as the MDP or the International Trachoma Initiative, but they show that WHO has been able to take advantage of the new policy tool of donations.

However, the time-lag between the creation of the MDP and the multiplication of other donation programs (when not explained by scientific constraints/drug availability) and the fact that they often did not assume an institutional shape as developed as the MDP highlight the importance of the long history of interactions and co-constitution processes between Merck and the WHO. The depth of cooperation between the two actors for 10 years before the set-up of the MDP seems to be an important factor in explaining why it worked in this case and why, in other cases, when there was no such history of in-depth interactions between the WHO and a pharmaceutical company, a cooperative relationship might be forged so that a specific drug is donated, but only on an *ad hoc* basis.

## The limits of public-private co-constitution

Whether the relationship with WHO is institutionalized or *ad hoc*, thanks to donation programs pharmaceutical corporations have taken the role of a co-producer of international health action. In their discourses, donations are presented as an act of charity belonging to a different sphere of activity than the for-profit one. However, this perception is misleading.

First, donations are in line with the market logic to which firms respond because the existence of market mechanisms is a condition for their implementation. The production of ivermectin for instance responds to the incentives of the veterinary market, and the decision to produce Mectizan was made in the hope of gaining a competitive advantage over other companies in the sector, in particular because it allowed the company better knowledge of and good contacts with health ministries.
Second, donations of medicines also fulfill a function of market protec-
tion. By providing a charitable mechanism intended to soften health inequal-
ities, they aim at avoiding the questioning of inequalities that result from the
very structure of the pharmaceutical market. As anthropologist Marcel Hénaff
points out, with the evolution of societies, gift-giving has undergone a process
of moralization: it is now an obligation for the rich to give back to society in
order to correct inequalities that threaten to break it up.⁸⁵ This analysis under-
pins a large part of the literature analyzing the development of philanthropy.
In the case of Mectizan, the donation was made by Merck as the company
gained unprecedented profits and strengthened its position in the pharmaceu-
tical market. In addition, the principle of a donation is to suppress the price,
which is a constitutive part of a market exchange. By eliminating this barrier to
access to medicines, firms avoid the questioning of the mechanisms by which
they otherwise determine prices. This ensures the protection of other compo-
nents of the pharmaceutical market such as intellectual property rights.⁸⁶ For
companies, the establishment of intellectual property rights makes it possible
to monetize innovation. In the case of drugs, companies argue that without a
patent, there would be no investment in research, no innovation and therefore
no progress in the health field. Jeffrey L. Sturchio, former Vice President of
Merck, very explicitly links the existence of strong intellectual property rights
to the possibility of a philanthropic action such as the MDP:

Doing well is a precondition to doing good: an enabling policy environ-
ment (including, for instance, adequate TRIPS⁸⁷-compliant intellectual
property protection standards) is a prerequisite for a company to have the
wherewithal to mount a major philanthropic program like the Merck
MECTIZAN Donation Program.⁸⁸

Thus, the effects of the reshaping of the fight against neglected tropical dis-
eases created by the drug donation programs should not be overestimated.
They do not imply a change in the core goals and views of the pharmaceutical
industry. It could be argued that the co-constitution of social protection pro-
cesses only applies outside the market, when Merck seems to act as a ‘moral
corporation’, even if this disconnection between the market and non-market
spheres is artificial, as the very existence of drug donations depends on the
perpetuation of market mechanisms.

*Debates on the ‘para-political’ institutionalization of corporate participation*

The questioning of this link between the market and non-market spheres
is especially relevant in a context of institutionalization of corporate partic-
ipation in IOs. Since the 1990s, the end of the Cold War and the rise of a
global governance era, there has been an increased participation of non-state
actors (NGOs, philanthropic foundations, corporations, etc.) in international
intergovernmental organizations and in the design of global public policies.
For instance, in 1992, so-called ‘Major groups’ were introduced at the United
Nations Conference on Environment and Development (also known as the
Rio Conference or the Earth Summit): the participation of several parts of
society (Indigenous Peoples, NGOs, Women, Children and Youth, Farm-
ers, etc.), including Business and Industry, was recognized and facilitated. In
2000, the UN created the Global Compact, an initiative to foster the coop-
eration between UN agencies and business. Since the turn of the twenty-first
century, global health initiatives or public-private partnerships have multi-
plied, and the WHO has actively engaged in them.⁸⁹ This way of engaging
in public policy, of providing public services, has long existed at the national
or local level, where there has always been a ‘mixed economy of welfare’.⁹⁰
Laura Lee Downs speaks, for instance, of a ‘para-political space of social pro-
tection’ that

straddled the gap between public and private. In this space, public func-
tions, [...] were assured by private or semi-public [...] actors working un-
der the benevolent, [...], eye of a state that had long recognized the social
protection of vulnerable populations as falling within its brief, but lacked
the means to organize and operate a full range of such institutions.⁹¹

However, this intensified and institutionalized cooperation between public
and private actors, for-profit and not-for profit, has sparked a debate on repre-
sentativeness and legitimacy. In particular, the issue of the ‘undue’ influence
on public policy by for-profit actors has been controversial. For instance,
some NGOs have denounced the UN Global Compact as a ‘blue-washing’
initiative (corporations using the Global Compact to enhance their legiti-
macy as ‘partners’ while in reality continuing to act contrary to UN princi-
ples and conventions). The issue of how to identify and manage conflicts of
interest has also become prominent, and in 2017, the UN Joint Inspection
Unit recommended that heads of UN agencies take measures in that regard
before the end of 2019.⁹² This ‘para-political space’ is thus very politicized,
traversed by political debates and antagonisms.⁹³

Conclusion

The Merck-WHO collaboration and the MDP are historically contextual-
ized developments, but they prefigure these contemporary debates, although
the answers provided at the time might differ from those of today. How to
incentivize corporations to contribute to the common good and to public
policy? The TDR Program was an attempt to do so through the creation
of a scientific network and embedding of individuals based on their scien-
tific ethos. The publicization around the MDP and the subsequent benefits it
brought Merck in terms of image was another means to this end.
Are there conditions in order for collaboration to lead to a more structured cooperation and an institutionalization? We were able to distinguish several stages of interaction, during which we have seen dynamics of interaction seeking/refusal, cooperation and competition. This case study emphasizes the importance of the building of interdependencies between actors and the role of individual brokers (such as Merck's scientists which were also involved with WHO), which are key elements of co-constitution processes. The depth of cooperation between Merck and the WHO for 10 years before the set-up of the donation program seems to be an important factor to explain its characteristics and sustainability, especially when compared to other programs which were designed differently, on an *ad hoc*, less comprehensive, basis.

How far can for-profit actors' preferences be influenced? While co-constitution processes took place and the WHO was able to frame some of Merck's actions (e.g. to insist on a long-term donation and to design community-led distribution strategies), their effects should not be overestimated as donation programs remain in line with core corporate for-profit goals and market mechanisms. However, we can notice that some issues which are now crucial were not raised at the time, such as the prevention of conflicts of interest to safeguard the legitimacy of an international program.

Thus, this chapter highlights the importance to map the history of interactions between public and private actors. Current debates on global governance and IOs dealing with non-state actors should not obscure past relationships. In this regard, a socio-historical approach and a thick description of case studies to track institutional processes and social interactions can be fruitful.

## Notes

1 Merck & Co. Inc., *Annual Report – 1988*, America’s Corporate Foundation, 1987, ProQuest Historical Annual Reports, 39; Merck & Co. Inc., *Annual Report – 1989*, America’s Corporate Foundation, 1988, ProQuest Historical Annual Reports, 2.

2 F. Hawthorne, *The Merck Druggernaut. The inside story of a pharmaceutical giant* (Hoboken, NJ, 2003), 12.

3 The same statue stands also in front of the World Bank in Washington DC and in front of the Carter Center in Decatur, Georgia, USA.

4 Fieldwork observation, Geneva, 2010, 2016.

5 The Carter Center, Interchurch Medical Assistance Inc., Interconex Inc., Fondation internationale pour les yeux, Organisation pour la prévention de la cécité, Rebecca & John Moores, Sight Savers International.

6 For more details, see J. Bump, ‘The Lion’s Gaze: African river blindness from tropical curiosity to international development’ (D.Phil, Johns Hopkins, 2004), 102.

7 There are many historical works in these areas. See for instance: P. Weindling (ed), *International Health Organizations and Movements, 1918–1939* (Cambridge, 1995); R. Cooter and J.V. Pickstone, *Companion to Medicine in the Twentieth Century* (London, 2003); D. Porter (ed), *The History of Public Health and the Modern State* (Amsterdam, 1994).

8 C. Geertz, ‘Thick description: Toward an interpretive theory of culture’, in C. Geertz, *The Interpretation of Cultures: Selected essays* (New York, 1973).
9 M. Diani, ‘Brokerage’, in D.A. Snow, D. Della Porta, B. Klandermans and D. McAdam (eds), *The Wiley-Blackwell Encyclopedia of Social and Political Movements* (Malden, MA, 2013).

10 On the notion of para-political space, see: L.L. Downs, "'And so we transform a people": Women's social action and the reconfiguration of politics on the French right, 1934–1947", *Past and Present*, 225 (2014), 187–225.

11 The seven other diseases part of the program in 1975 are: African trypanosomiasis, Chagas disease, leishmaniasis, leprosy, lymphatic filariasis, malaria and schistosomiasis. Since 2000, the TDR portfolio has extended to tuberculosis and dengue.

12 TDR, *Report of the first external review committee*, Final report TDR/JCB(5)/82.6, 30 June 1982, 51.

13 Pharmaceutical companies often possess property rights on biological compounds or molecules, but do not necessarily test them to see if they might be useful to develop a treatment against diseases they are not interested in. In order that these compounds do not stay 'on a shelf', TDR incentivizes companies to send their compounds for testing somewhere else by setting up the necessary research capacities, such as screening centers. In the case of lymphatic filariasis and onchocerciasis for instance, TDR counts three primary screening centers (in the United States, Japan and Great Britain), two secondary centers (in Greece and Germany) and two tertiary centers (in Australia and Malaysia). Pharmaceutical companies such as Bayer, Ciba-Geigy, Hoechst, Hoffmann La Roche, Janssen, Merck, Parke-Davis Warner-Lambert, Rhône Poulenc, and Tanabe Chemical used at some point one of these screening centers. In: TDR, 'Outline of the TDR Filariasis SWG Activities since 1976 in the search for improved chemotherapy for onchocerciasis' (December 1981), 7; WHO Headquarters, *WHO Archives*, File CDS1-NTD-OPC Fol 135/A0FF-0836 on the Mectizan donation program/OCP - Onchocerciasis Control Program.

14 K. Benson, quoted in T.A. Börzel, 'Organizing Babylon. On the different conception of policy networks', *Public Administration*, 76, 2 (1998), 257.

15 TDR, 'Outline of the TDR Filariasis SWG Activities since 1976 in the search for improved chemotherapy for onchocerciasis' (1981), 7; WHO Headquarters, *WHO Archives*, File CDS1-NTD-OPC Fol 135/A0FF-0836.

16 Novartis Archives, *Firmenarchiv Ciba-Geigy*, KL 4 (Novartis is the pharmaceutical company that absorbed Ciba-Geigy).

17 Some pharmaceutical companies, such as Abbott Laboratories, produce them.

18 Pharmaceutical corporations and their business association, the International Federation of Pharmaceutical Manufacturer Association, backed by a few powerful governments such as the United States, strongly opposed these regulations which impacted their commercial activities. For more details see A. Guilbaud, *Business Partners. Firmes privées et gouvernance mondiale de la santé* (Paris, 2015), 45–56.

19 WHO Headquarters, *WHO archives*, File T16/370/1 J. 4.

20 TDR, *Document TDR/JCB(5)/82.6.*, op. cit., 42.

21 *Ibid.*, 39.

22 TDR, Third external review, reference document 3, Document No.TDR/ER/RD/98.3. (1998).

23 TDR, 'Outline of the TDR Filariasis SWG Activities since 1976 in the search for improved chemotherapy for onchocerciasis' (December 1981), 7; WHO Headquarters, *WHO archives*, File CDS1-NTD-OPC Fol 135/A0FF-0836 on the Mectizan donation program/OCP - Onchocerciasis Control Program.

24 L. Frost, M.R. Reich and T. Fujisaki, 'A partnership for ivermectin: Social worlds and boundary objects', in M.R. Reich (ed), *Public-private Partnerships for Public Health* (Cambridge, MA, 2002), 93–94.
25 *Ibid.*, 93.

26 'William C. Campbell – Biographical', Notice on the Nobel Prize website, https://www.nobelprize.org/prizes/medicine/2015/campbell/biographical/ (accessed 16 October 2019).

27 K.L. Collins, 'Profitable Gifts. A history of the Merck Mectizan® Donation Program and its implications for international health', *Perspectives in Biology and Medicine*, 47, 1 (2004), 104.

28 *Ibid.*, 103.

29 *Ibid*.

30 There is an important record on the development process of ivermectin for human use, whose complete and detailed account is beyond the scope of this article. See for instance: W.C. Campbell, 'The genesis of the antiparasitic drug ivermectin', in R.J. Weber and D.N. Perkins (eds), *Inventive Minds: Creativity in technology* (Oxford, 1992).

31 P.R. Vagelos and L. Galambos, *Medicine, Science, and Merck* (Cambridge, 2004), 249.

32 Dr. Aziz passed away on November 25, 1987, shortly after the Mectizan Donation Program was announced.

33 Vagelos and Galambos, *Medicine, op. cit.*, 249.

34 'Mohammed A. Aziz, Researcher, 58', *The New York Times* (1987), 27.

35 WHO Headquarters, *WHO archives*, File CDS1-NTD-OCP Fol 135/A0FF-0836.

36 J.W. Houck and O. Williams (eds), *Is the Good Corporation Dead? Social responsibility in a global economy* (Lanham, MD, 1996), 45.

37 A.M. Samsky, 'Humanitarianism, science and the market in two international drug donation programs' (D.Phil, Princeton, NJ, 2009), 55.

38 *The Lancet* is a respected and well-known weekly medical publication founded in 1823.

39 A. Rougemont, 'Ivermectin for onchocerciasis', *The Lancet* (1982), 1158.

40 P.R. Vagelos and L. Galambos, *The Moral Corporation: Merck experiences* (Cambridge, 2006), 164.

41 M.A. Aziz, S. Diallo, M. Lariviere et al., 'Letters to the Editor. Ivermectin in onchocerciasis', *The Lancet*, 320, 8313 (1982), 1456-1457.

42 S. Omura and A. Crump, 'The life and times of ivermectin, a success story', *Nature*, 2 (2004), 986.

43 L.A. Tavis, *Power and Responsibility: Multinational managers and developing country concerns* (Notre-Dame, MI, 1997), 256.

44 WHO Headquarters, *WHO archives*, File CDS1-NTD-OCP Fol 136/A0FF-0836, 'Letter from M. Warren Furth, WHO Assistant Director General, to M. John Lyons, Executive Vice-President, Merck & Co. Inc., 22 September 1987'.

45 L.K. Altman, 'New drug may curb tropic "river blindness"', *The New York Times* (1 August 1982).

46 U.S.'Neill, 'A conversation with P. Roy Vagelos', *The Journal of Clinical Investigation*, 124, 6 (2014), 2291-2292. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4089453/ (accessed 17 October 2019).

47 J.E. Dutton and M.G. Pratt, 'Merck & Co., Inc. From core competence to global community involvement', in N.M. Tichy, A.R. McGill and L. St. Clair (eds), *Corporate Global Citizenship. Doing business in the public eye* (San Francisco, CA, 1997), 157.

48 WHO Headquarters, *WHO archives*, File CDS1-NTD-OCP Fol 135 – A0FF-0836, 'Memo: Summary of meeting regarding ivermectin, April 30 1987' and 'Doc. OCP/GVA/86.1 – Potential use of ivermectin in the Onchocerciasis Control Program in West Africa, October 1986'.

49 Vagelos and Galambos, *The Moral Corporation, op. cit.*, 132.

50 L.M. Bates, 'Donation policy study', in M.R. Reich (ed), *An Assessment of US Pharmaceutical Donations: Players, processes, and products* (Boston, MA, 1999), 89.
51 Merck & Company Inc., *Annual report* – 1989, op. cit., 40.

52 Merck & Company Inc., *Annual report* – 1987, op. cit., 2.

53 *Ibid.*, 258.

54 W.H. Foege, '10 years of Mectizan', *Annals of Tropical Medicine & Parasitology*, 92, supl (1998), S7-S10.

55 Interview, Merck & Co., Inc., 2011.

56 WHO Headquarters, *WHO archives*, 'Memo: Summary of meeting regarding ivermectin, April 30 1987', op. cit. and 'Doc. OCP/GVA/86.1', op. cit.

57 WHO Headquarters, *WHO archives*, 'W. Furth's letter to Mr. John Lyons', op. cit.

58 P. Cerny, 'The process of personal leadership: The case of de Gaulle', *International Political Science Review*, 9, 2 (1988), 132-136.

59 P.A. Rea, V. Zhang and Y.S. Baras, 'Ivermectin and river blindness: Science and philanthropy put an end to blindly following the next generation', *American Scientist*, 98, 4 (2010), 297.

60 Vagelos and Galambos, *The Moral Corporation*, op. cit., 2.

61 *Ibid.*, 3.

62 Hawthorne, *op. cit.*, 36.

63 *Ibid.*, 17.

64 WHO Headquarters, *WHO archives*, Letter from M. Warren Furth to M. John Lyons, *op. cit*.

65 Interview, Task Force for Global Health, 2011.

66 Frost, Reich and Fujisaki, *op. cit.*, 97.

67 WHO Headquarters, *WHO archives*, File CDS1-NTD-OCP Fol 136/A0FF-0836.

68 V. Mitchell, N.M. Philipose and J.P. Sanford (eds), *The Children Vaccine Initiative: Achieving the vision* (Washington, DC, 1993), 59.

69 WHO Headquarters, *WHO archives*, File SCHISTO1-INFCO-DRUG.

70 Interview, Task Force for Global Health, 2011.

71 WHO Headquarters, *WHO archives*, File EIP1-RPC Fol 65/A0FF-0757.

72 B. Colatrella, 'The Mectizan donation program: 20 years of successful collaboration. A retrospective', *Annals of Tropical Medicine & Parasitology*, 102, 1 (2008), 9.

73 Interview, Task Force for Global Health, 2011.

74 J. Levine, 'Sharing power. How Merck and the WHO have sustained a fragile balance of power in their battle against river blindness', *Stanford Social Innovation Review*, 3, 3 (2005), 67.

75 WHO Headquarters, *WHO Archives*, File CDS1-NTD-OCP Fol 136/A0FF-0836.

76 *Ibid*.

77 *Ibid*.

78 The Alma-Ata declaration was published during the Alma-Ata International Conference on Primary Health Care that took place in URSS/Kazakhstan on September 6–12, 1978 and was organized by WHO and UNICEF. It was an important turning point in terms of strategy for WHO and the public health community in general. Health was recognized as a human right and as depending on socio-economic and political conditions. It contained an appeal to achieve 'Health for All' by the year 2000, thanks to a strategy of 'primary healthcare', which is based on 'universal access and coverage on the basis of need; health equity as part of development oriented to social justice; community participation in defining and implementing health agendas; and intersectoral approaches to health'. WHO, *The World Health Report 2003. Shaping the future* (Geneva, 2003), 103.

79 Omura and Crump, *op. cit.*, 987.

80 Interview, Task Force for Global Health, 2011; Levine, 'Sharing power', *op. cit.*, 59.

81 'Uche Amazigo receives major recognition', TDR news item (20 February 2013). Available at: https://www.who.int/tdr/news/2013/uche_amazigo/en/ (accessed 28 October 2021).
82 S. Kohler, 'The tropical disease program. Edna McConnell Clark foundation, 1974', in J. Fleishman, S. Kohler, S. Schindler, *Casebook for the Foundation: A great American secret* (New York, 2007), 130.

83 Interview, Merck & Co., 2011, and Interview, FSG Social Impact Advisors, 2011.

84 The list of medicines donated by pharmaceutical companies against neglected tropical diseases is available at: https://www.who.int/neglected_diseases/medicine-donation-04-march-2019.pdf?ua=1 (accessed on 11 May 2019).

85 M. Hénaff, 'La nouvelle philanthropie capitaliste', *L'Homme*, 167-168 (2003), 312.

86 A. Guilbaud, 'Generous corporations? A Maussian analysis of international drug donations', *Journal of International Political Theory*, 14, 2 (2018), 203-222.

87 The agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is the international treaty regulating intellectual property rights on a global scale. It is managed by the World Trade Organization (WTO), and all WTO member States have to abide by its rules.

88 J.L. Sturchio, 'The case of ivermectin: Lessons learned and implications for improving access to care and treatment in developing countries' (2001). Available at: https://www.wto.org/ENGLISH/tratop_e/trips_e/hosbjor_presentations_e/21sturchio_e.pdf (accessed 21 May 2019).

89 Guilbaud, *Business partners, op. cit.*

90 M.B. Katz and C. Sachbe (eds), *The Mixed Economy of Social Welfare. Public/private relations in England, Germany and the United States, the 1870's to the 1930's* (Baden-Baden, 1996).

91 Downs, *op. cit.*, 189.

92 Joint Inspection Unit, 'Review of mechanisms and policies addressing conflict of interest in the United Nations system, JIU/REP/2017/9' (Geneva, 2017).

93 A. Guilbaud, 'Transferts et continuités de la politisation à l'Organisation mondiale de la santé: Le cas des substituts du lait maternel', *Critique Internationale*, 76 (2017), 101-119.

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<figure><img src="image_8.png" /></figure>

Taylor & Francis

Taylor & Francis Group

http://taylorandfrancis.com
Index

abbé Pierre 58, 70

anarchism 138–139, 142, 144

Angers 43–44, 47, 50

Anthony de Gaulle, G. 61, 64, 71

Asia Minor 108, 112

*Association nationale du soutien de l'enfance*
*see* National Association for the
Support of Children

ATD Fourth World 60–62, 64, 66, 70–71

Athens 108, 113–119

Aziz, M. 188–189, 192–193

Basch, V. 138, 141

Basque autonomous government
140, 148

Belgium 62, 66, 73, 132, 139, 143, 162,
169, 173

Berlin 43, 45–46, 49

Bilbao 140, 148

Blanco, S. 144, 149

Bochum 43, 45

Bouchet, P. 70–71

Breslau 43, 45

British Empire 160, 169

brokers 9–12

Buisson, G. 138, 143

Campbell, W. 188–189, 192–193, 199

Canada 162, 173

Catholic charities 5, 7, 43–57, 59, 63, 65,
68, 70–71, 147, 166

Central Delegation for Colonies
142–143

Champendal, M. 22–23

charities and charitable sector 5, 16–35,
43–57, 59, 63–64, 107, 109, 147, 200

childcare: France 44–47, 49–50, 59;
Greece 112, 113–116, 121; Spain
136–138, 142–144, 146, 148–150;
Swiss 17, 18–22, 26–33, 36, 38, 41

children 112, 114, 118–119, 132–150

Ciba-Geigy 186, 199, 204

city councils 5, 9, 12, 17, 97; Belgium
161; France 45, 47, 50, 59, 65, 67,
71–72, 73; Germany 45, 48, 50–51;
Greece 108–109, 116–117; Poland
92, 95–98, 102, 120; Spain 140;
Switzerland 24, 34

civil code: France 18; Swiss 17–21,
24–28, 33

civil servants 10, 107–122, 141, 143, 145,
148, 150, 160–161

civil society 9, 107, 122

Clark E. 163–164

Clouzot E. 168–169

Cologne 43, 48

Comas, J. 143, 145, 147–149

Commission on the cost of living of
family workers: Poland 84–86, 89,
92, 95

Communist Party: France 135, 137; Spain
136, 142, 144, 146

congregations: Catholic 44–45, 47–50

*Consejo nacional de la infancia evacuada*
*see* National Council for Evacuated
Children

*Consejo Superior de Protección de Menores*
*see* High Council for the Protection of
Minors

conservatism 108, 111

corporations 183–188, 191–192, 197,
200–201

Council for Cultural Relations 146–147

de Gaulle, C. 61, 64

*Delegación central de colonias escolares see*
*Central Delegation for Colonies*

*Delegación española para la Infancia*
*Evacuada see* Spanish Delegation for
Evacuated Children
Doctors of the World 65, 71

Doctors Without Borders 65, 69, 71, 72

drug donation 182–183, 185, 190–191, 193–194, 196–201, 203, *see also*

Mectizan Donation Program

Eastern Europe 1, 6–7

Elberfeld 45, 48, 50–51

Elbeuf 43–45

elderly care 2–3, 44–45, 47, 49–50, 59, 61, 64, 67

Emmanuelli, X. 69, 72

Emmaüs 60–61, 63, 65, 67–69, 71

employment: France 6, 60, 64–69, 73; Poland 80–84, 86–90, 94, 99

Enfants de Don Quichotte 68, 70

Europe 61, 107, 112, 160–161, 164–165

European Union 61–62, 67

experts 10, 70, 160, 162, 167–169, 171, 174, 184, 186–188, 193, 195–199, 203

families 59, 64, 80, 85, 94, 98, 101, 109, 120, 133, 135, 140–141, 145, 148–149

feminism 111, 112–113

First World War 79–81, 83, 87, 90, 112, 133, 150, 159, 164

*Fortune* 182, 198

Foundation abbé Pierre for the housing of the Underprivileged 69, 70

foundations 184, 191, 195–196, 199–202

*Foyer Notre-Dame des sans-abri* 60, 63, 70

France 2, 5, 9–10, 43–58, 62–63, 65, 67–68, 72–73, 112, 132–150, 162

Frankfurt 43–45

French Economic and Social Council 62, 66

French Popular Relief 60, 63, 65, 69

Fuss, H. 162, 167, 173, 174

Geneva 16, 21, 26, 114, 161–164, 168

Germany 2, 5, 9, 43–57, 66–72, 112, 132, 162, 163, 172–173

Giscard d'Estaing, V. 61–2

GlaxoSmithKline 199–200

*Główny Urzęd Statystyczny* see Central Statistical Office

Great Depression 171–172

Greco-Turkish War 108, 110, 112

Greece 6–7, 10, 107–108, 112, 114–115, 118, 120–121

Guinopoulou, E. 111, 114

handicapped 59, 64

*Haut comité pour le logement des défavorisés* see High Committee on Housing for the Disadvantaged

healthcare 59, 66, 68, 109, 117, 120, 183–188, 190–200, 204, 206

Hernández, J. 142–144, 149

High Committee on Housing for the Disadvantaged 70, 72

High Council for the Protection of Minors 139–140, 144

homeless 63, 66–69

hospitals 45, 49–50, 71

housing 60, 67–68, 70

humanitarianism 133–134, 150

Human Rights League: France 65, 137–138; Spain 137, 141

Hurlbutt, M. E. 162–163, 171

inflationary crisis: Poland 80–81, 83–84, 88, 86–90

in-home relief 44–45, 50–51

Institute of Social Economics 6, 10, 79, 82–85, 87–89, 93–100

*Instytut Gospodarstwa Społecznego* see Institute of Social Economics

insurance 59, 73

International Association on Unemployment 161–162, 164, 166–167

International Conference of Labour Statisticians 90–91, 93, 97

International Conference on Emigration and Immigration: Havana 169, 171; Rome 165–167, 169

International Emigration Commission 161–165, 167

International Labour Conference 166–167, 169, 170, 173

International Labour Office 84–86, 88–95, 97, 99, 159–175; Emigration and Unemployment section 162, 167; Governing Body of the ILO 161, 167–168

International Labour Organization 7, 159–161, 164, 167, 169

International Migration Service 162–163, 168, 171–174

International Trachoma Initiative 199–200

International Save the Children Union 113
Interwar period 72, 79, 86, 101, 105, 108–112, 110, 121, 160

Italy 114, 132, 165

Jewish Colonisation Association 165–166, 169, 173

Jewish charities 44, 48, 165

judges 111, 118–121

*Junta de Relaciones Culturales see Council for Cultural Relations*

jurists 110–113

juvenile courts 111–113, 118–120

Kipa, L. 170–171

Kreutz, Dr 172–173

Largo Caballero, F. 138–139

Larned, R. 168–170

Lausanne 27, 32

lawyers 118, 120

League for Women's Rights 111–112

League of Nations 159–160, 165, 168–169, 171–172, 174; Child Welfare Committee 171

Lenoir, R. 61, 64

liberalism 8, 110–114

*Liga española de derechos humanos see Human Rights League, Spain*

*Ligue des droits de l'homme see Human Rights League, France*

Little Sisters of the Poor 45, 47

Łódź 83, 92, 95–98

London 162, 165

Luxembourg 164–166

Lyon 43, 48, 65, 68–69

Madrid 132–133, 136, 138, 140

Maestre, M. 140, 143

market 185, 187–188, 190–191, 194, 199–201, 203

Mectizan Donation Program 7, 11, 182–185, 191, 193–202

Merck 7, 10, 187–190, 192–194, 198–200

Mexico 132, 142

Michelis, G. De 165–166

migrant-protection organizations 160–161, 164–166, 168

migrants 59, 67, 70, 145–146, 150, 159–172, 174

military 108, 118

Ministry of Culture, France 64

Ministry of Education, Spain 8, 132–134, 142–150

Ministry of Foreign Affairs, Spain 138

Ministry of Justice, Greece 111–112, 119

Ministry of Public Health and Social Security, France 64

Ministry of Social Protection: Austria 3, Poland 79, 82; Spain 134, 137–142, 145, 148

Montseny, F. 138–144, 146

mothers 22, 24, 35

municipalities see city councils

Münster 48, 50

Nancy 43–45, 47–48, 50

National Association for the Support of Children 135–137

National Confederation of Labour 138–139, 142, 144

National Consultative Commission on Human Rights 70, 72

National Council for Evacuated Children 133, 143, 147, 149

National Council of Greek Women 112–113

National Organization of Christian Solidarity 115–116

national sovereignty 159, 161, 174

Negrín, J. 142, 144

neoliberalism 1, 58

Neuilly 43–45, 47, 50

NGOs 174, 182, 184, 191–192, 195–198, 202

Novartis 184, 200

nursery 45, 47, 50, 110, 121, 136

Omura, S. 188, 199

Onof, M. 135–136, 138

orphanages 44, 47, 49–50, 109, 120

Orthodox Church, Greek 112, 116–117

Paris 47, 49–50, 70, 132, 135–137, 140–141, 143, 164, 169, 173

Permanent Conference for the Protection of Migrants 7, 160, 164, 168–174

Permanent Migration Committee 167, 169

philanthropy 3, 58, 64, 72, 109–111, 114, 122, 201

physicians 111–112, 118, 121, 144, 189, 192–193, 197

Piraeus 114, 119

Poland 6, 10, 79–89, 93–95, 98, 162, 170

police 116; 115, 117
poverty: France 6, 43–57, 60–62, 64–66, 69, 73; Germany 43–57; Poland 80–81, 84–86, 89–94, 98–99

Prime minister: Spain 137–138, 142

Pro Familia 32–33, 35

Pro Juventute 17, 24–25, 34–35

Protestant charities 43–44, 46, 48–49, 51, 65, 147, 162

Prussia 46, 49

Python, G. 19–20

Reception Committee for Spanish
Children 133, 137–150

Red Cross: America: 133–134; general
115, 168–169; Greece 115–116

reformers 111–112

refugees 110, 112

Rome 165–167, 196

Rouen 43, 47–48, 50

Russia 79, 80–81, 83, 90

Sabrás, A. 137, 141, 143, 148

Saint-Étienne 43–45

Samusocial 69, 72

schools 45, 47–48, 50, 109, 120, 140, 144–149

Schwander, R. 50–51

Second World War 6, 59, 108–109, 111, 114–115, 117, 145, 183

*Secours populaire see* French Popular Relief

Silesia 83, 95–96, 98

Skouriotis, P. 112–114

Socialist Party: France 135; Spain 136

social reformers 144, 159

social workers 110–111, 162, 170, 174

Society for the Protection of Minors 111;
118–120

soup kitchens 116–117

Soviet Union 132, 142–143; see also
Russia

Spain 6–7, 132–139, 142, 144–147, 149–150

Spanish Civil War 132–150

Spanish Delegation for Evacuated
Children 143–149

statisticians 70, 79, 87–93, 97–99, 9, 100–101; see also experts

Statistical Office: Central office Poland 6,
10, 79–80, 82, 84–86, 88, 92, 94–100;
Labour Statistical Office Vienna 93,
97–98; Warsaw statistical service 88,
95–98

Steamship companies 161, 167, 169–171

Strasbourg 43–47, 49–51, 67

Switzerland 5, 24–25, 115, 139, 162

Szturm de Sztrem, T. 87–89, 100–101

Task Force for Child Survival 188,
195–199

teachers 110, 138, 140, 142–147, 150

Thessaloniki 108, 118–120

Thomas, A. 159, 161–169, 174

trade unions 84–88, 91, 95–97, 99–100, 102, 117, 137–138, 140, 161, 166

UNICEF 185, 195

United Kingdom 2, 7, 9, 58–59, 66, 72, 107, 132, 162

United Nations 184–185, 191, 202

United States 1, 2, 9, 58, 61, 72, 112, 160–162, 164, 169–171, 173, 183, 185, 190–191, 195, 204

Vagelos, R. 190, 192–193

Valencia 138, 140–142

Varlez, L. 161–169, 172–174

Vaud 22, 31

Venizelos, E. 110, 114

vulnerable groups 108–109, 111, 112, 114

Warsaw 81, 83, 87–88, 98

Washington DC 161–162

welfare state 1–2, 5–9, 58–60, 107, 114, 117

West Africa 183, 188, 190, 197

Western Europe 1, 108

Wolf, L. 165–169, 171–173

women's care 22, 24, 35, 45, 47, 49, 121

women's movement 19, 31, 35, 110–113, 118, 120, 136, 160

workers 20, 59, 64–66, 68, 80–81, 83, 85–90, 94–96, 99–100, 159, 161; budget surveys of workers' families 92–98

Workers' International Relief: French
135–136

World Bank 182–183, 185, 189, 195, 203

World Health Organization 7, 10, 183, 186, 189–192, 195–198

Wresinski, J. 61, 62

Wuermeling, B. 48, 50–51

Würzburg 43, 44

Young Men's Christian Association
162, 166

Young Women's Christian Association
162–164, 166