There is little doubt that the coming years will see a tsunami of books and journal special issues analyzing the global pandemic and its implications for every little corner of society. Major crises obviously call for scholarly reflection; however, crises can easily fool us into viewing the past merely as precursor to the current crisis. Prepandemic books on the World Health Organization (WHO) may appear outdated, but they are also happily unpretentious in not offering the definitive prequel to the COVID-19 pandemic. The two recent volumes by Wu and by Cueto, Brown, and Fee both benefit from this prepandemic bliss and add important chapters to the growing global health scholarship.
A core contribution of these works is to underline the unique worldview that characterized the first generation of WHO officials. Wu characterizes this worldview using Sheila Jasanoff's notion of dreamscapes (Jasanoff and Kim 2015). A dreamscape can be understood in this context as a “sociotechnical imaginary” that connects a collective normative vision with a series of technological tools and knowledge forms. So, while the dreamscapes of world health do involve “dreamy” ideals, they are also connected to the material and technological realities of international health activities, such as vaccination programs or disease classifications.
Parts of the early WHO worldview have been analyzed before from various angles, including the key role of Brock Chisholm, WHO's first director-general (Farley 2008), and the organization's revolutionary preamble that defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Larsen 2022). Much of the scholarship on global health organizations, however, tends to emphasize either the continuities with international health organizations before World War II (Borowy 2009; Weindling 1995) or the WHO's later efforts under headlines such as decolonization, North–South dynamics, or efforts to eradicate disease (Amrith 2006; Chorev 2012; Packard 2016).
Few would of course be surprised to know that World War II had a huge impact on the WHO founders, but the scale of the dreamscapes in the early WHO is often overlooked. First, some of the founders clearly imagined that the WHO would be able to spread universalist health policy and social security institutions across the globe (Larsen 2022). Second, Brock Chisholm imagined that the burgeoning threat of nuclear war would not only unite the world in a joint effort to promote “positive” health but that it would also lay the ground for some sort of utopian “world citizenship” (Wu 27–28). Finally, the title of Wu's book—Mad by the Millions—describes how the founders of WHO's mental health programs imagined that there would be endless numbers of war survivors in need of psychiatric care, an idea that created a new understanding of the “universality” of mental illness (12). With all these lofty ideals and dreamscapes as the starting point, however, the WHO's honeymoon period ended quite bluntly in the early 1950s, when Cold War politics really set in and the prospects for world citizenship and positive health evaporated.
The volume by Cueto, Brown, and Fee offers by far the broadest and most detailed overview of the WHO's history, from the preceding international health organizations in the 19th and early 20th centuries through a long series of major health challenges and postformative stages that defined the organization. The book clearly fills a gap, because earlier works have either pursued a particular organizational perspective on the WHO (Hanrieder 2015; Lee 2009) or have essentially been autobiographies of the organization itself (Howard-Jones 1978). In contrast with the former group, this book does not offer any elaborate theoretical or methodological framework besides rich historical description. The book does not advertise any overarching narrative or approach, but rather prioritizes giving a solid chronological account of the organization's main leaders, conflicts, reforms, and not least its main health challenges throughout its history.
The authors do identify an important tension in the WHO's early years between social medicine on one side and a biomedical and technocratic approach on the other. As the book progresses, this tension recedes somewhat into the background through most of the chronological chapters describing the WHO's work on malaria, reproductive rights, smallpox, HIV, tobacco control, and various pre-COVID pandemics (SARS, H1N1, and Ebola). The sociomedical perspective resurfaces in the coverage of the 1978 Alma-Ata declaration on primary health care and more recent initiatives on social health disparities and universal health coverage.
Wu's work on mental health in the WHO is a different type of book entirely. Although it also covers some of the institutional history, it is first and foremost an intellectual history of how leading psychiatrists in the WHO mental health program understood mental illness. His analysis of the dreamscape of world mental health connects with approaches from science and technology studies. According to Wu, it was the specific combination of normative ideals of world health and the technical underpinnings of mental health classification that enabled the founding generation to develop such grand modernization plans for world mental health. Besides offering more theoretical reflection on the very categorization of mental illness, this approach gives the book a distinct and original narrative that is not simply reducible to medicalization or the power of Big Pharma.
The story begins in WHO's early years, when mental health suddenly received much more attention than it had before. The WHO's health definition placed mental health on the same level as physical and social health (Larsen 2022), and with a psychiatrist as the first director-general, the lofty ambition to move millions of people out of war trauma and into some sort of world citizenship set a completely new scene for global mental health policy. Based on Chisholm's efforts to generalize military and war psychiatry, an important expert committee was formed in 1948 to develop a unified definition of mental illness. Chisholm's goal was to extend the treatment of soldiers with specific war trauma to the prevention of mental illness in the wider public, and to explore thematic key emphases, from child health to the experiences of technological automation in postwar society.
While the chief ideologues in Geneva were spreading these grand ideals of world citizenship, the experts commissioned to develop a universal classification of mental illnesses encountered a lot more problems during their work in the 1950s and 1960s. The most fascinating part of Wu's analysis is the slow and gradual development of methods from an early stage, when the expert group set out to transfer a largely epidemiological toolbox to the field of mental health. This led to the development of surveys and classifications of individual characteristics, which would ultimately lay the foundation for the International Classification of Diseases. Medical classification had been the cornerstone of international health and quarantine agreements since at least the mid-19th century, but to transfer those principles to the psychiatric area proved more than difficult. Not only is it harder to develop an unambiguous classification of disorders such as schizophrenia or clinical depression than of most infectious diseases; because mental illness diagnoses are always made by people who may have different understandings of what constitutes “excessive drinking” or other symptoms (Wu 119), the diagnostic process also is hard to standardize and rationalize to the extent that the early WHO expert group imagined.
An additional set of complications arrived when these universal aspirations had to be globalized to all the world's corners, languages, and cultures. The complications were not simply the product of money, power, and Cold War politics; Wu's analysis also shows how the development of mental health classification systems encountered what historian of science Gaston Bachelard would call “epistemological obstacles.” It was simply not possible to set up a monitoring system that would automatically make all clinicians classify mental illness in the same way, since, for instance, different cultures and languages use different categories to distinguish normality and deviance. This may sound like common sense today, but this book effectively demonstrates the importance of this insight in the setup of diagnostic classifications in psychiatry.
Another key contribution of Wu's analysis is its careful sequencing of stages and steps from the 1940s to the present. The sequence demonstrates that, perhaps contrary to common perception, the development of diagnostic classifications was in fact not initially driven by the pharmaceutical industry, even if the classification certainly facilitated an expansive market for psychoactive drugs later. As Wu (29) shows, diagnostic classification was not really driven by scientific research as such either; rather, it was driven by a belief in “scientific internationalism,” which was later opposed by a countermovement that wanted a better representation of cultural differences in the classification and treatment of mental illnesses.
If we compare the two recent works on the WHO, they both offer elaborate analyses of an extensive internationalism in the organization's early period. Both works are structured chronologically and therefore read as being more episodic rather than aiming for any overarching argument. Indirectly, however, a key element in both books is not just the continuities in WHO history but also the discontinuities. Both books analyze how the bold idealism and wild dreamscapes of WHO's formative period came crashing down when faced with Cold War politics, pandemics, or in Wu's case, the practical obstacles to making a universal definition and classification of mental health. These discontinuities often cause the formative zeitgeist to be either overlooked or interpreted merely as prequel to the present.
If we return to the present, does this scholarship help us understand the controversies around WHO's role in the global response to the pandemic? In fact, it does, because no one having read Cueto, Brown, and Fee's opus on WHO history would be surprised to find the organization being weak and torn when faced with opposing global superpowers. This was to some extent always the case and is yet another testimony to the major split between idealistic dreamscapes and the organization's weak power and resources to produce world health. This is the case not because the organization lacks talent, commitment, or expertise, and not because it is controlled by China or other foreign powers, but perhaps because the early ideals of the WHO are precisely what fool us into believing that an organization with few resources and formal powers can simply overcome interests and politics in global health policy.