The Politics of Healthy Wellbeing between International and US Health Policy

• In Event: The Expansion of Health Policy and Public Health: Historical Perspectives

Abstract

In a variety of national and international contexts, health policy goals today are defined as a sort of ‘wellbeing’, a more broad, positive and subjective understanding of health that goes well beyond disease treatment. For example, the World Health Organization defines mental health as "... a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (WHO 2004). Similarly, human wellbeing is a key factor in the UNDP’s Human Development Index, a combined measure of health and socioeconomic factors. There is extensive scholarship in moral philosophy about the proper meaning of wellbeing in its various subjective and objective dimensions, but almost nothing has been written on wellbeing as a political goal. How, why, and with what implications did health come to be defined as ‘wellbeing’? This paper aims to answer this question through a genealogy of the political process in which wellbeing emerged as a core health policy objective. The research is based on original archival material from the World Health Organization, the United Nations Archives, the League of Nations Archives, the National Archives (US) the FDR and Truman Presidential Libraries, the National Library of Medicine, and the archives of the International Labor Organization.
The connection between health and wellbeing goes back to the formation of the WHO whose constitution famously defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO 1948). This is clearly more inclusive of public health and social medicine than the dominating understandings in organized medicine at the time, and as such, the definition is part of the entrenched conflict, not least in the United States, about the role of government in health care. However, the inclusion of ‘wellbeing’ is also the result of another power struggle in the same period about expanding the domain of international health.
During the establishment of the United Nations system between 1942 and 1948, a turf war and a struggle for survival broke out between international organizations, some leftovers of the League of Nations and others prospective new organizations with visions of a new commitment to international health after the war. On one side of this struggle, the founders of the WHO wanted a broad and progressive mandate that would not only include disease eradication and medical classification, but also core welfare areas such as health insurance and social security. On the other side, the International Labor Organization, a remnant of the former international system, similarly tried to expand its ‘social mandate’ to include the “the promotion of (…) health, education and well-being” (ILO 1944). The WHO founders were furious about this perceived intrusion and to reclaim the territory they thought was rightfully theirs, they inserted the term ‘wellbeing’ into the WHO’s constitutive health definition.
While the turf war played out between international diplomats, each party had various branches of the US government fighting for them. The FDR White House was more committed to the ILO and work conditions than to international health, whereas the Truman administration seemed more committed to a new health organization. The State Department and the US Public Health Service worked hard to lobby for the WHO, while the US Congress on the other side dragged its feet in terms of ratifying the WHO constitution including its progressive ideas about positive health and wellbeing. In other words, struggle over the domain of international health spilled over into a domestic conflict in US health policy, for instance surrounding President Truman’s proposal for national health insurance.
Ultimately, both the WHO and ILO survived, while Truman’s health reform did not. The connection between health and wellbeing even made it into the Universal Declaration of Human Rights from 1948 which declares a human right to “health and well-being”. The ‘and’ clearly illustrates how the power struggles over the scope of health policy – domestic and international – did not simply connect the dots between the goals of health and wellbeing. They also established wellbeing as a flexible container, an ultimate end all health interventions should aim for, and which clearly reaches beyond health policy to broader areas of welfare, social security and human development.

Author

• Lars Thorup Larsen, Aarhus University