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.Instead the RF s model of health cooperation was transported, largelyintact, over time and place.At the same time as the RF was involved in country-by-country cooperation, it wasalso influencing, directly and indirectly, the international health field writ large.Through its pioneering disease campaigns and other public health activities, theRF provided the groundwork for a new international health system featuring itsown bureaucracy, legitimacy, and mode of conduct.Where other agencies, such asthe PASB and the OIHP, remained for many years focused on disease surveillanceand the protection of commerce,1 the RF developed a more extensive under-standing of international health cooperation.The LNHO was partially modeledafter the IHD and shared many of its values, experts, and know-how in disease con-trol, institution-building, and educational and research work.Despite the capabledirection of Polish hygienist Ludwik Rajchman, the LNHO was mired in League ofNations politics, and budgetary constraints meant that it could realize only part ofits ambitious agenda.2 Rather than being supplanted by the LNHO, the IHD servedas its major patron and took over some of its key activities during World War II.3As the premier international health organization of its day, the RF had anoverarching purview and leadership role.It was instrumental in establishing thecentrality of international health activities to the realms of diplomacy, economicdevelopment, state-building, and scientific diffusion, and it institutionalized thepatterns of health cooperation that remain in place to the present day.The prin-ciples that were infused both in the RF s dealings with Mexico and in the inter-national health field as a whole are undoubtedly the RF s most important legacy:virtually all subsequent international health activities have been influenced onsome dimension by these deeply-embedded principles. epi logue 269The PrinciplesThe hallmark of the RF s approach to international health derived not so muchfrom particular successes in the field which were molded by multiple influ-ences and typically claimed regardless of the outcome as from the way RFcooperation was organized.What an analysis of IHD activities in Mexico eluci-dates, then, is the mix of tenets, operating policies, and practices which enabledthe RF to adapt to almost any political situation and to work in numerous set-tings simultaneously amidst a complicated swirl of local and foreign interests.Many of these ideas were developed first by colonial offices and other inter-national agencies,4 but it was the RF that sharpened them, made them work inconcert, and applied them in a consistently effective manner.The RF s modus operandi can be crystallized into five principles of inter-national health cooperation, each of which is linked with a range of conse-quences.The principles also combine with one another in synergistic fashion,with further implications for the ideas, strategies, and practices of internationalhealth.First is the principle that donor interests, rather than locally defined needs,determine the nature and focus of international health cooperation throughdirect in-country activities or the awarding of grants.The agreements betweenthe RF and host governments such as those governing the yellow fever cam-paign and local health units in Mexico allowed the RF, through its administra-tors and country-based officers, an important role (albeit one subject tonegotiation) in the design and implementation of cooperative activities and,indirectly, of the country s larger public health agenda.At the same time, thisarrangement shielded the RF from domestic public health embroilments.TheRF also furnished cooperation based on renewable grants as was seen in tar-geted malaria research support in 1940s Mexico with the RF s agenda-settingrole exercised through grant application, reporting, and renewal processes.This principle of agenda-setting from above as practiced by virtually alldonor organizations has significant bureaucratic implications.Extensivedonor involvement means that international agencies like the RF have to createtheir own bureaucracies to recruit and oversee officers, develop policies,approve and monitor activities, and maintain an internal infrastructure to keepthemselves going.Once these systems and practices are institutionalized, inter-national agencies are able to define and pursue high-profile global strategies,streamlining demands on the agencies and facilitating accountability.Second is the principle that cooperative activities while driven by donoragendas require substantial cooperative financing from recipient countries.As we saw in the case of the hookworm campaign in Mexico, host countries wereto provide considerable material, office, and personnel support to RF-sponsoredcampaigns.The host country was also expected to furnish a portion of the fund-ing for each activity from the outset and gradually to become fully responsibleg' 270 epi logueg'Table E.1.RF principles of international health cooperation(1) Agenda-setting from above: international health activities are donor-driven,with the agenda of cooperation formulated and overseen by the interna-tional agency, whether through direct in-country activities or the awardingof grants.(2) Budget incentives: activities are only partially funded by donor agencies;matching fund mechanisms require recipient entities to commit substantialfinancial, human, and material resources to the cooperative endeavor.(3) Technobiological paradigm: activities are structured in disease control termsbased upon: (a) biological and individual behavioral understandings of dis-ease; and (b) technical tools applied to a wide range of settings.(4) A priori parameters of success: activities are bound geographically, throughtime limits, by disease and intervention, and/or according to clear exitstrategies in order to demonstrate efficiency and ensure visible, positive out-comes.(5) Consensus via transnational professionals: activities depend on transnationalprofessionals, who are trained abroad (often with donor agency staff) andinvolved in international networks, easing the local translation of cooperativeendeavors.for both financing and operations.These budget incentives were designed toencourage the sustainability of programs, while limiting the RF s financialresponsibility in any one setting.Given that national matching funds were oftenlarge enough to displace other spending priorities, this arrangement served toextend the RF s agenda-setting powers well beyond the cooperative activity itself.Accompanying the donor role in agenda-setting is the third principle, of atechnobiological paradigm guiding international health projects.The RF wasinstrumental in furthering this enduring paradigm that cooperative activitiesfocus upon the control of particular diseases; that diseases are understood prin-cipally in biological and behavioral terms; and that standard technical tools beemployed in the control of each disease, regardless of the setting.Typically, theRF selected one of a handful of highly visible disease campaigns yellow fever,hookworm, or malaria each with a specific etiology and a known technicalapparatus (such as a medication, chemical prophylaxis, or method of behaviorchange).If the ailment was not a leading local problem or if the campaign failedto prevent the recurrence of the disease because it did not address the ailment sunderlying factors (as in the case of hookworm), this approach was neverthelessretained
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