Cora Du Bois’ Brief Stint With the World Health Organization (1950–1951): Right Time,Wrong Place

Chisholm’s World Health Organization

In his very first speech, as a member of the Technical Preparatory Committee that drafted the WHO Constitution in the spring of 1946, Chisholm opposed the opinion that the aims of the organization should be limited in scope: “The world was sick, and the ills from which it was suffering were mainly due to the perversion of man, his inability to live at peace with himself.” He associated himself with the “visionaries.” What was taking place would be of great historical importance “if all members aimed at universal and worldwide achievement. To do this, they might find it necessary to bite off more than they could chew, but the alternative was complete chaos.” ^{5 (p13)}

Chisholm was unanimously elected director-general by the first session of the Executive Board on July 18, 1948; he took the oath of office on July 21 as the first World Health Assembly (WHA) was drawing to a close.

Historians who have written about WHO’s first years of existence have reached more or less the same conclusion (the diminished attention to integrated health services and social medicine) but via different routes. Sunil Amrith, for example, argues that the shift from “more expansive notions of rural public health” to a “public health centered on technology … owed much to the global circulation of DDT … ” ^{6 (p47)} James Gillespie has described how the World Medical Association (WMA), along with those of Britain and America, forced the WHO to retreat from taking a strong stand on social security, which included health insurance. The WMA resistance was a “part of wider campaign against state medicine and to keep a watchful eye on the statist tendencies within the WHO.” ^{7 (p232)}

Many historians have also written about how the Cold War affected the work of WHO. The availability of DDT, combined with the growing threat of Communism, pushed malaria control to the forefront. As noted by Randall Packard and Peter Brown, the need to “win the hearts and minds of people in developing countries led to calls for more interventionist approaches to development,” which allowed people in international health “to concentrate on mosquitoes and not to be concerned with thorny problems of poverty and inequalities in the distribution of land and capital resources.” ^{8 (pp186–187)}

Socrates Litsios added another consequence of the Cold War, namely that it led to a

distortion of the priorities of global programs being carried out by the various U.N. agencies. Preference was given to countries where the threat of Communism was judged to be greatest. Preference was also given to more quickly achieved results that placed anti-Communist governments in a “good light.” ^{9 (p271)}

John Farley identified the “first obvious signs that the Cold War had infected the WHO” as being the speech given by Nikolai Vinogradov, the Soviet chief delegate to the first World Health Assembly. ^{11 (p62)} This is a very astute observation, as Vinogradov faulted the Interim Commission (IC) for having “done very little to strengthen the position of the national health services,” which the Soviet delegation believed to be “the first and most important” task of WHO. The Soviets were proud of their health services and were highly critical of those of America, where “medical aid must be paid for, very often at a cost beyond the reach of the great majority of the population.” ^{11 (pp40–41)}

The structure of the organization was “complex and clumsy and not conducive to the best interests of the work, largely due to the fact that the IC had hurriedly created more than 15 different committees and subcommittees with various functions and composed of a large number of members.” ^{11 (p40)} The Soviet Bloc withdrew from WHO the following year, thus depriving WHO of any further criticism of this kind, at least from the Soviet Bloc. As well, their departure “left the field open for American initiatives.” ^{6 (p85)}

American observers to the first WHA did not pick up on Vinogradov’s criticism. Instead, as observed by Russell, Vinogradov’s speech was judged to be a “long harangue” in which he complained of “pitiful palliative measures” of the IC, the epidemics caused by “poverty and colonial oppression,” and how there was “practically no VD and alcoholism in the Soviet Union.” ¹² Of more immediate importance was the Soviet position concerning the acceptance of the United States as a member state of the WHO, which required a unanimous decision on the part of the WHA. Henry van Zile Hyde, the U.S. representative to WHO, was present as well. He too noted that Vinogradov was “blasting the U.S.,” but when Stampar, who was chairing the session and who understood Russian, broke out into a “big grin” … “we knew we were in.” ^{13 (p66)}

Russell, who was an avid reader of books concerning the major problems facing mankind at the time, such as famine, rapid population growth, and fear of a nuclear war, was probably aware that Chisholm was a strong advocate of world citizenship and that he feared that “the next war could mean the suicide of the human race.” ^{14 (p99)} In the United States such words were considered to be un-American and associated with Communist sympathizers. In fact, Chisholm “held many views that the American right would have considered treasonous.” ^{11 (p190)} As Russell was fiercely anti-Communist, one can imagine that this also influenced his attitude toward Chisholm.

It is unsure if Russell’s attitude toward the Soviet Union prevented him from taking seriously Vinogradov’s criticism of WHO’s structure, particularly as it applied to the strategic direction in which the malaria expert committee (one of the very first of the 15 committees established by the IC under the guidance of Russell) was leading WHO.

Du Bois did not refer to any of these tendencies in her papers, but given her often critical comments concerning the manner in which American foreign assistance was being provided, there can be no doubt that, had she engaged in discussions concerning the “social” dimensions of health, she would have sided with Chisholm and the other progressive public health leaders of that time.

Anthropology in the Early Work of WHO

WHO’s mental health program seems to have been the first to specifically indicate the need for anthropologists. The mental health program had as one of its objectives “the solution of the emotional and social problems which arise when modern science and technology are introduced into communities whose culture has for centuries been an agricultural one.” In such situations the “skills and knowledge of the cultural anthropologist” was seen as being needed to show health workers “who are seeking to put the benefits of medical science within the reach of the people of such a community, how they can most effectively adapt their methods to changing cultural conditions.” ^{15 (p214)}

Another recognized need for anthropologists was in gathering qualitative information concerning food habits, food patterns, and food preparation practices. The Pan American Health Organization (PAHO) hired Richard Adams to undertake nutritional research in Guatemala that had been started earlier and later on to conduct cultural surveys of Panama, Nicaragua, Guatemala, El Salvador, and Honduras. ¹⁶ Before joining PAHO, Adam had belonged to the Smithsonian Institution’s Institute of Social Anthropology (ISA), where he worked with George Foster. When the latter program was terminated, it was taken over by the Institute of Inter-American Affairs (IIAA), the first American technical aid program of modern type, and the forerunner of USAID. Hyde directed the IIAA.

PAHO’s Health Promotion Branch, which was organized in 1952, appointed Edward Wellen, an anthropologist, “to make special studies of the health program at Ica, Peru.” ^{17 (p46)} Before joining PAHO, Wellen was with the Rockefeller Foundation’s Division of Medicine and Public Health. The project itself had been launched in 1945 with the guidance of Dr. J. L. Hydrick, author of the volume Intensive Rural Hygiene Work in the Netherlands East Indies, which was published in 1938. This is one of the rare instances where a direct linkage can be seen between pre-WWI and immediate post-WWII rural hygiene endeavors.

The work of both Adams and Wellin found their way in Benjamin D. Paul’s Health, Culture and Community: Case Studies of Public Reactions to Health Programs, ¹⁸ a volume that Foster judged to be “the single most widely read and influential book in all of medical anthropology.” ^{19 (p191)}

WHO’s African Region was also sympathetic to the involvement of anthropologists in health work, as can be seen from what Dr. Daubenton, its first regional director, had to say to the Executive Board in January 1954: “it was impossible to consider health and disease in Africa as isolated factors; the environment, sanitary engineering problems, and social and anthropological conditions had also to be taken into account.” ^{20 (p7)} Dr. Pierre Dorolle, deputy director-general of WHO, went further; he wrote of the “absolute necessity to associate ethnological studies with all health actions.” ^{21 (p315)} Dorolle was one of the very few individuals still engaged in international health work who had participated in the 1937 Bandoeng Rural Hygiene Conference; he also was responsible for having Hydrick’s book translated into French and Spanish.

Dorolle engaged Jean-Paul Lebeuf, a very eminent French ethnologist, to work for WHO’s African regional office for several years in the early 1950s. At the end of his stay with WHO, Lebeuf wrote L’Application de l’ethnologie à l’assistance sanitaire, in which many references are made to Dorolle’s papers on the subject. In turn, Dorolle drew upon Lebeuf’s work to illustrate the role of ethnologists in public health work, especially concerning health education of the public.

Despite these examples, a study carried out in the early 1950s to evaluate assistance projects concluded: “It is a curious anomaly that despite the many general references to the social contributions of health work, almost all of the attention of professional health personnel appears to concentrate upon the biological factors.” ^{22 (p13)}

They Never Asked Her to Do Anything

Martha Eliot, head of Advisory Services at WHO’s headquarters in Geneva, was responsible for Du Bois’s engagement with WHO. Eliot’s program consisted of 3 divisions: communicable diseases, public health services, and education. Of the 3 departments that made up the WHO Secretariat in Geneva, only Advisory Services had direct responsibility for field activities. Du Bois was able to study these divisions before going on to India, where according to Eliot, she would act “as a sort of interpreter to WHO of various cultures of the areas in which WHO has programs or projects.” It was Eliot’s hope that future WHO programs “may have the advantage of a preliminary and contemporary study of the social aspects of health work in backward areas.” ²³

Du Bois’s arrival at WHO was announced in a list of appointments and departures on January 1, 1950. No date of arrival was given. She wrote a 2-page interoffice memorandum, dated March 20, 1950, that places her in Geneva that month. Entitled Miscellaneous Observations Prior to Reaching Geneva, one learns that before arriving in Geneva she had visited New York (the Rockefeller Foundation); London (the Tavistock Institute of Human Relations, the African Division of the U.K. Colonial Office, the U.K. Colonial Social Science Research Council, the London University, and the London School of Economics); and Paris (UNESCO). From these visits she drew “some partial and premature conclusions”:

The lack of adequately trained social science personnel is generally agreed upon. Verbal support of the multidisciplinary approach is increasingly common. However, planning and operational practice lag behind verbal statements. Evaluations of the effectiveness of technical assistance programmes are rare and seem not to be included in agency programmes. National and international programmes appear to be progressing in a piecemeal fashion. If one assumes that societies are integrated, piecemeal approaches may be either inefficient or set off unforeseen and uncontrollable “chain reactions.” ²⁴

Eliot and Chisholm had decided to station Du Bois in New Delhi, WHO’s South-East Asia Regional Office, whose director was Dr. C. Mani. Russell, who never seemed to have met Du Bois, learned of her assignment shortly after Du Bois departed for New Delhi. From Eliot he learned that Du Bois would visit India, Malaya, and Indonesia “to obtain a social understanding of what WHO is doing and what public health means.” ²⁶

From Russell’s diary, it seems that it was Eliot who passed on the gossip concerning Chisholm’s comparing Du Bois to malaria teams. Of more immediate importance was Eliot informing Russell that Mani “was disgusted” with the idea that Du Bois had been engaged. When Russell saw Mani after having met with Eliot, he found him “still sputtering about the cultural anthropologist.” ²⁶ It is no surprise that Du Bois would later say her “reception by Dr. Mani – an Indian military medic – was not cordial. I was left to make my own plans and schedules and I was more than a little perplexed as to what was expected of me.” ¹ (^p24) Mani was an authoritarian figure, as suggested by the fact that he believed (until he learned otherwise) that “he could tell the Indian ministry what they could do and what they couldn’t do.” ^{13 (p76)}

One has to wonder what provoked Russell to make such entries in his diary. The only logical reason that I can think of is that he fully agreed with Mani.

Once settled in New Delhi, Du Bois busied herself by visiting projects in the field of her own choosing, reporting her findings to memorandums mostly written to Mani. Not surprisingly, given Mani’s attitude toward her appointment, she did not seem to spend enough time in the regional office to write about it.

Her first report to Mani concerned the Council for Social Work, which was located at the University of Delhi. Du Bois used her report to outline what social scientists might do “if WHO/SEARO develops an interest in using social science consultants in planning projects or in attempting to overcome resistances in projects under way”; it could engage the schools’ personnel that she had identified “on a temporary consultant basis.” ²⁷ There is no indication that their services were ever called on.

Du Bois used her visit to the Indian Village Service (IVS) to begin her critical assessment of the manner in which WHO carried out its health projects. Developed by William Wiser, whom Du Bois characterized as “a man trained in social science and with many years of experience in varied villages and projects,” the IVS approach was

in almost every respect antithetical to the approach employed in WHO. ²⁸ IVS attempts to approach village problems on an integrated basis rather than by attacking a single aspect of village problems. IVS begins by promoting education for self-help rather than the furnishing of competent technical services. IVS encourages the villagers to define their needs rather than diagnosing needs for them. IVS initiates rather than completes undertakings and therefore does not have tangible accomplishments to report. IVS estimates that 3 years are required to initiate some changes in attitudes. WHO works on a shorter schedule and does not direct its efforts primarily at changes in attitudes on the village level.

She found a “most successful” example of integration in the Ramanagaram Health Demonstration Project, which was one of the 4 Rockefeller Health Demonstration units that she visited in India. ²⁹ The medical officer, Dr. Chandrasekhar Araya, who had established the project, was a person of “considerable vision and energy.” Immediately upon the establishment of the health unit, he “insisted” on the establishment of a parallel Rural Development Center, which concerned itself with agricultural improvements, cottage industries, technical education, housing, village planning, etc. Furthermore, he continued his interest in this project when becoming director of public health for Mysore State. Du Bois’s preference for projects in which health was integrated with other aspects of social welfare is evident in the enthusiastic manner in which she described this and other similar projects.

Another major theme in her writings concerned what she termed “the need for mutual adaptation,” especially on the part of “personnel trained in western medicine,” known for “their uncompromising attitude toward even harmless local customs.” Her advice took different forms depending on location. For example, after having visited projects in Northern Thailand, she “urge[d] that all international personnel recruited for work with Thais be temperamentally capable of relaxed, gracious and smiling behaviour, and that they possess some degree of sensitivity to unfamiliar modes of courtesy.” ³⁰

She brought together her ideas on this subject in an unpublished paper entitled The Social Framework for Technical Assistance, which formed the basis for a talk to technical assistance personnel given sometime in 1952, i.e., shortly after having left WHO. In it, Du Bois laid out what she believed those involved in technical assistance should be aware of, after first indicating an anomaly that she had observed among certain American (and other foreign) technicians, namely their “singular obtuseness, and even rigidity, born of a profound conviction of what is right.” As a group “we have made ourselves conspicuous in the Far East by insisting on having our own kind of housing, clothing, food, churches, schools, and the thousand and one appurtenances of our own culture.” It is not “we, the exponents of change who are expected to change. It is rather our stereotypes of the conservative traditionalists of whom we expect change.” Seeing this situation as one with “profoundly revolutionary potentialities,” she suggested that the roles of technicians should not be so much to hasten changes as to “assist them into adaptive rather than destructive channels.” ^{31 (p3)}

She used different examples to get her listeners to reflect more carefully on the origins of their beliefs, as illustrated by this short excerpt: “It seems to me not improbable that as much folklore has grown up around scientific discoveries in our society as has grown up around the life of Buddha in Burma. This has impressed me particularly in respect to sanitation. No one would deny the reality of bacterial infections, but I find, as a lay person, the greatest difficulty in extracting from my medical friends where science stops and folklore begins in that whole range of behaviour we prefer and justify as sanitary and hygienic. I know only that I am vastly bewildered when Indian friends assure me that a peasant mud house nearly plastered with cow dung is both clean and hygienic. I am also bewildered when the same Indian friend confesses that he finds our western system of bathing in tubs and therefore in a brew of our own soiled water singularly repulsive.” ^{31 (p4)}

Dr. Marcolino Candau, who joined WHO as a medical director in April 1950 and would succeed Chisholm as director-general in July 1953, wrote to Du Bois requesting “a frank statement” concerning “the use of social scientists in WHO.” ³² In her brief opening paragraph, she wrote that it was her opinion that

competent planning, the selection of personnel, the training of recruits in the social implications of their work, the most effective reporting and the assessment of WHO’s operational effectiveness form one closely inter-related complex. In all of these functions, one or another of the social sciences have [sic] an important role to play.

In October 1950 Du Bois drafted Some Comments on the Planning of WHO Operations, with an indication that she would “greatly” appreciate “corrections, disagreements, amplifications and editorializing.” ³³ Again, there is no record of her having received comments of any kind.

Her opening paragraph indicates the importance she ascribed to operational planning:

The planning of activities in any organization is one of its most basic and vital functions. The philosophy and procedures brought to bear on planning as well as the imagination, experience and thoroughness marshalled over the course of years will go far to solve the allied problems of briefing, evaluation, reporting, recruiting and selection of personnel, relations with other organizations.

Program planning is usually undertaken by functional specialists, which, depending on the nature of the function addressed, may range from the general to the specific. While such plans may “be excellent in themselves,” to assure the “most effective use of WHO funds and personnel” should be weighed against a set of criteria which Du Bois labeled as “neither complete nor original”: On how broad an informational and diagnostic basis has the project been framed? Does it fit into other, nonmedical, developmental schemes? Does it fit into a total health development program for the area? What contribution will this project (compared to others submitted) make to the welfare of the people of the area – conceived in its broadest terms? What expectation of permanence has the project? Is the economic trend of the area likely to permit continuing financial support by the government? Is technical competence for the maintenance of the project assured in local training facilities, fellowships, etc.? Is there any evidence of popular support for the project or is any education for such support included? Who has participated in framing the project? Have all relevant government agencies been consulted, and have working-level personnel been brought in as early as possible in the planning? What specialists have been or should be consulted in finalizing this project? Is there evidence that technical personnel as well as supplies are genuinely wanted?

Problem planning was, according to Du Bois, “the type most rarely found in organizations giving technical assistance,” as it implied “the selection of a key difficulty in a social or geographic unit, the solution of which leads to series of chain reactions throughout the unit selected.” It requires a “sound social diagnosis,” one that includes as “an important force, the ‘felt need’ of a country, whether at the governmental level or at the village or ‘grass root’ level.” Du Bois recognized that problem planning presented “many difficulties” – persons capable of that type of planning were “rare”; cooperation between individuals and coordination among agencies were often “troublesome matters”; and the social sciences from psychology to economics were “not sufficiently developed to furnish easily applicable guides for reliable social diagnosis.” ^{33 (p5)} Du Bois also recognized that her discussion of planning was “frankly a largely academic analysis” but which she felt to be useful as it established “certain standards by which to measure WHO activities.”

She then went on to discuss various types of WHO field projects, in which she was able to make several critical observations:

Concluding Observations

In comparing the disappointments of DuBois’s [sic] assignment with the positive results of the work of those who shortly followed her, a critical difference in the institutional setting stands out. No one in WHO was interested in Dubois’s work. In contrast, the work of Wellin [and] Adams was successful in large part because of the interest and support of strategically placed culturally sensitive public health physicians: Hydrick in Peru … and Hyde in the IIAA. ^{19 (p192)}

Writing in 1982, Foster wrote that to the best of his knowledge there was “no inventory of anthropologists who worked in international health programs.” ^{19 (p192)} He clearly did not know of the work of Lebeuf in Africa. There is thus no reason to suspect that he knew of the supportive roles that both Dorolle and Daubenton played in promoting the involvement of ethnologists and anthropologists in WHO projects in Africa. In this same article he noted how “a generation ago physicians and anthropologists alike defined the problem of providing better health care for traditional peoples as how to persuade them to accept scientific medicine.” ^{19 (p189)} This clearly indicates that he had no knowledge of Du Bois’s work at WHO, since her work never had such an aim. Her work didn’t even fit his description of the role of anthropologists at the time of his writing – to contribute to the understanding of “sociocultural aspects of health and illness behavior [and] to learn about the dynamics of ‘community participation’ in health care programs.” ^{19 (p189)}

In 1968, at a meeting where “culture, disease and health services” were discussed, Foster observed:

“To work successfully in a strange culture or subculture, one must understand the social organization, cultural forms, and values (i.e., bureaucracy) of the innovating organization and of the wider society of which it is a part. Today’s sophisticated planners ask the most searching questions, not about the client group towards whom their efforts are directed, but rather about themselves, the implicit premises that underlie their professional attitudes, the interpersonal relations characterizing their fields, the psychological adjustments of technicians and administrators to their levels of activity and authority, and a hundred similar questions. ^{37 (p174)}

While it is tempting to blame Du Bois’s disappointment on Dr. Mani, the above suggests that she may not have fared any better with those physicians sympathetic to the role of anthropologists in public health. This is borne out by the fact that John Grant, ³⁹ who is considered one of the most progressive public health administrators of that period and who was “personally interested in determining the value and results accruing from Clara Dubois’ [sic] consultative services on Social Anthropology” was disappointed in what he learned about her work. He found her papers on planning “not to have any anthropological content.” ⁴⁰

Had Mani greeted Du Bois with open arms and asked her to help the malaria projects improve their educational methods, it is hard to imagine that she would have refused; it’s not possible, however, to judge if this would have been a satisfactory assignment for her, but it is certain that she would have had critical comments to make, perhaps of a different kind.

Clearly Du Bois was an exceptional individual with a rather unique career. How many other social scientists had spent long periods of time living with and studying culturally diverse peoples and even a much greater period of time organizing military spying missions? That no one in WHO seemed to have paid any attention to her ideas reflects badly on the WHO. On the other hand, as suggested by Foster’s observations, she was way ahead of her time. She did not fit the role expected of anthropologists. WHO needed then, as it does today, her kind of critical observations.