IELTS Academic Reading Practice Test 362

Long before there was a World Health Organization, governments made attempts to coordinate the fight against disease across frontiers. Cholera epidemics in the 1830s and 1840s persuaded European powers that infection could not be stopped at a border, and in 1851 the first International Sanitary Conference met in Paris to agree rules on quarantine. Further conferences followed, but agreement was slow. In the Americas, a regional body that eventually became the Pan American Health Organization was founded in 1902, and in 1907 an international office for public health was set up in Paris to collect information about outbreaks of plague and cholera.

The First World War interrupted this cautious cooperation. Its aftermath produced new machinery: the League of Nations established a health organisation in the early 1920s, which sent expert commissions to study epidemics, nutrition and rural health and did much to standardise the naming and measurement of diseases. Meanwhile the Paris office continued its work on quarantine. The result was a patchwork of bodies with overlapping duties, limited funds and no authority over the countries they served, and the Second World War scattered even this arrangement.

By 1945 the need for something better was obvious. The United Nations Relief and Rehabilitation Administration, created in 1943, had found itself fighting typhus and malaria across liberated Europe and Asia with little coordination between countries. At the founding conference of the United Nations in San Francisco in 1945, the delegations of Brazil and China proposed that a general health organisation be created, and the conference endorsed the idea. In the first half of 1946 the United Nations Economic and Social Council called a conference to draw up a constitution.

A technical preparatory committee met in Paris in the spring of 1946 to draft proposals, and the International Health Conference then met in New York from 19 June to 22 July 1946. Delegates from 61 states took part. On the final day they signed the Constitution of the World Health Organization, a document of nineteen chapters that set out the new body's objectives, its governing assembly and its executive board. Because not all the signatories could ratify it immediately, the conference also established an Interim Commission to keep essential health work going in the meantime.

The Constitution opened with a statement of principle that has been quoted ever since, defining health as 'a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity'. This was a deliberate break with older thinking. It implied that ministries of health should concern themselves with housing, nutrition and working conditions, not only with hospitals and medicines, and it gave the new organisation a mandate far wider than that of any of its predecessors.

The Interim Commission, based in Geneva, absorbed the staff and functions of the League's health organisation, the Paris office and the health division of the relief administration. Its resources were modest and its authority provisional, but it faced real emergencies. An outbreak of cholera in Egypt in 1947 was among the first, and the commission helped to coordinate the response, finding supplies of vaccine and disinfectant and sending experts. It also began the unglamorous work that was to define the organisation: standardising the names of drugs, agreeing how vaccines should be tested, and building a network of expert committees.

Ratification took nearly two years. The Constitution required the formal approval of 26 of the 61 signatory states before it could come into force, and the twenty-sixth approval was deposited in the spring of 1948. On 7 April 1948 the Constitution took effect, and that date is still marked each year as World Health Day. The organisation itself, however, was not yet operating: it needed staff, a budget and a leader.

The first World Health Assembly met in Geneva in June 1948, with delegations from the countries that had by then ratified the Constitution. It approved a programme and a budget, chose the Canadian psychiatrist Brock Chisholm as the first Director-General, and adopted an emblem: the rod and serpent of Asclepius, the symbol of healing in Greek medicine, laid over a map of the world. Chisholm, who had been the commission's executive secretary, insisted that health depended on social as well as medical conditions.

Those campaigns were ambitious. Mass treatment with drugs was beginning to make it possible to attack diseases that had previously been left alone, and the new organisation committed itself to malaria, tuberculosis, yaws and venereal disease, alongside maternal and child health and the training of health workers. Yaws, a bacterial infection of the skin and bones that affected millions of people in the tropics, was attacked with penicillin in campaigns that lasted for years. In 1951 the Assembly adopted the International Sanitary Regulations, a single set of rules replacing a tangle of earlier agreements and giving the organisation a genuine role in monitoring outbreaks around the world.

The results were uneven, and the organisation learned by experiment. Campaigns that depended on spraying insecticides against malaria gave way, when resistance appeared, to more patient work on drugs and bed nets. But one effort succeeded completely: in 1980 the World Health Assembly declared that smallpox had been eradicated, the first human disease to be wiped out by deliberate international action. A body that had begun as a compromise between earlier offices in Paris and Geneva now had a record of its own.

A vaccine works by teaching the immune system to recognise a pathogen without the patient having to suffer the disease. Most vaccines contain either weakened or killed micro-organisms, fragments of them, or a harmless extract such as an inactivated toxin. Some of the newest are made from genetic material that instructs the body's own cells to produce a single viral protein. Whatever their design, almost all share one characteristic: they are biological products whose potency depends on the precise three-dimensional shape of proteins and other large molecules, and that shape can be destroyed by conditions that would leave a bottle of pills entirely unaffected.

Two kinds of damage threaten a vaccine. The first is heat. Warming accelerates the chemical reactions that unfold proteins and break the bonds holding large molecules together, and the warmer the vaccine becomes, the faster the damage accumulates. A vial that has spent a day at 30°C may lose potency that no amount of subsequent refrigeration can restore, because the change is chemical rather than merely physical. Exposure to light causes its own damage, which is why many vaccines are supplied in brown glass or in boxes that must be kept closed.

The second threat is cold. Freezing damages almost every vaccine, though in different ways. Water expands as it turns to ice, and the crystals that form can rupture the containers holding the antigen; more importantly, many vaccines contain aluminium salts, added to strengthen the immune response, and these clump together irrevocably once frozen. A vaccine that has been through a freezer may look perfectly normal while carrying far less protection than its label promises. Freeze-sensitive products therefore have to be kept above 2°C at every stage, a requirement that is easily broken in the field, where ice is the standard means of keeping things cool.

The international standard for most vaccines is a refrigerated range of between 2°C and 8°C, from the moment of manufacture to the moment of injection. A few are stored frozen instead. The oral polio vaccine, for example, has traditionally been kept at -20°C or colder for long-term storage, and varicella vaccine is also held frozen. Freeze-drying, in which water is removed from the product under vacuum, makes some live vaccines far more stable, and a freeze-dried vaccine can often tolerate weeks at room temperature, though the liquid used to dissolve it before injection usually cannot.

The chain that results is a sequence of stores and vehicles, each with its own equipment. Vaccines travel from the factory in refrigerated containers, are held at a national store, then move by lorry, boat or motorcycle to regional and district stores and finally to clinics. At each step the insulation has to be renewed. Cold boxes, lined with frozen ice packs, carry several days' supply; smaller vaccine carriers are used for a morning's outreach in a village. Because an ice pack straight from a freezer is far colder than 2°C, staff are trained to condition the packs, leaving them at room temperature until the ice begins to melt at the edges.

Monitoring has become more systematic. Electronic data loggers record temperatures continuously and can be downloaded when a shipment arrives, and simple cards with heat-sensitive windows provide a crude record of the highest temperature reached. The most useful innovation is the vaccine vial monitor, a small square of heat-sensitive material printed on the label of many vials.

Its inner circle darkens gradually as the vaccine is exposed to heat, in a way that reflects accumulated exposure rather than a single reading, and health workers can therefore see at a glance whether a vial is still usable. Introduced in the 1990s, the monitors have allowed vaccines to be taken to communities far from any refrigerator.

Substantial uncertainties remain. A single reading above 8°C is easy to interpret, but most real journeys involve repeated small excursions, and there is no simple way to convert a temperature history into a prediction of how much protection a batch has lost. Freeze damage is harder still to detect, because a frozen vial looks like any other; the standard field check is a shake test, in which a suspect vial is shaken beside a known good one and the two are compared for clumping. In remote facilities, meanwhile, nobody may be recording temperatures at all.

Research is slowly changing the picture. Manufacturers have produced more heat-stable versions of several existing vaccines, and drying a vaccine into a glassy solid, in which molecules are held in place by sugars, can protect it at tropical temperatures. A meningitis vaccine designed for Africa was the first to be licensed for use outside the cold chain for a limited period, provided it was kept below a stated temperature, and it was used in mass campaigns without refrigeration. Researchers are also developing microarray patches, smaller than a fingernail and coated with dried vaccine, which would need no needles, no trained injector and no cold chain at all.

Yet the weakest point in any cold chain is rarely the equipment. Reports on vaccine wastage repeatedly identify the same problems: too few working refrigerators, unreliable electricity, staff who have never been shown how to pack a cold box, and deliveries that arrive without warning. The last kilometre, from a district store to a village health post, is where most exposure happens. Solving it requires not a better device but a routine that survives staff changes, and that is considerably harder to design.

Every health system rations care, whether it admits it or not. Waiting lists, insurance rules and the distance a patient must travel all determine who receives treatment and how quickly. Age is a different kind of criterion. Everyone who lives long enough acquires it, which makes it simultaneously the least arbitrary characteristic imaginable and the one that provokes the most unease. During the Covid-19 pandemic, hospitals and national bodies in several countries published protocols for allocating scarce intensive care, and in some of them age played a part. The reaction was fierce.

Two quite different arguments are usually confused in this debate. The first is predictive. Age is strongly associated with frailty, with multiple long-term conditions and with a reduced chance of recovering from major surgery or intensive treatment, so a doctor who knows nothing else about a patient can infer a good deal from age alone. Using age in this way is a shortcut to a judgement about likely benefit. The second argument is about fairness between lives, and it claims something much stronger: that a year of life saved is worth more when the person saved has had fewer years already.

The most direct statement of that second view came from the American bioethicist Daniel Callahan. In Setting Limits, published in 1987, he argued that medicine had lost sight of the difference between prolonging life and caring for people, and that a society which spends a growing share of its health budget on the last months of life buys very little for the money. He proposed a natural lifespan, ending somewhere in the late seventies or early eighties, beyond which the state's obligation to fund life-extending treatment should weaken, while care, pain relief and dignity remained guaranteed.

A more elegant version was offered by Alan Williams, an economist at the University of York, who borrowed a phrase from cricket. His 'fair innings' argument holds that every person is entitled to a reasonable span of life, which he put at roughly seventy years, and that someone who has already had that span cannot reasonably complain if resources go to those who have not. The claim is not that an old person's pain matters less, but that the good being distributed — years of life — has already been received in full. It is an argument about equity, not about the value of individuals.

Norman Daniels, an American philosopher, approached the problem differently. Rather than asking how to divide resources between age groups at a single moment, he invited his readers to imagine planning a whole life, and to ask what each of us would prudently set aside at every stage if we did not know how old we would be. His answer was a scheme in which resources are spread across the stages of life as a prudent planner would spread them, so that the very old receive less for cure and more for care. On this account, treating age differently is not discrimination between people but fairness between the stages of one person's life.

Against all three, the British philosopher John Harris has argued that the fair innings case rests on a mistake. A life is valuable to the person whose life it is, he maintains, and the fact that someone has already enjoyed many years does not make the next year worth less to them than a young person's first. To prefer the young because they have more years ahead is to value people for their capacity to generate future years rather than for themselves, and from there it is a short step to the view, which few would defend openly, that the old and the disabled matter less.

Practical objections carry at least as much weight as philosophical ones. Age is an average, and averages conceal the person in front of the doctor. An active woman of eighty-five may tolerate an operation better than a sedentary man of sixty, and a rule that began as a way of predicting benefit ends up withholding it from precisely the patients who would have gained most. There is a further danger that an explicit age limit would become an excuse for underfunding, allowing governments to present a saving as a principle.

The pandemic offered an instructive test. Where hospitals wrote down their criteria in advance, published them and submitted them to public argument, the result was uncomfortable but defensible; where clinicians rationed quietly, by deciding whom not to admit, the result was a system that nobody could inspect and nobody could appeal against. Openness also made the choices better, because a rule that must be justified in public is a rule that has to be argued for. The alternative to explicit rationing is not the absence of rationing but rationing by discretion.

My own view is that age should inform decisions about treatment but should never make them on its own. A doctor is entitled to weigh the likelihood that a particular patient will benefit, and that likelihood is affected by age along with many other things; a health system is entitled to ask how much benefit it is buying with a given sum.

What it may not do is substitute a birth date for an assessment of the person. Where age enters the calculation it should do so openly, on stated evidence, and with the presumption that care and the relief of suffering are owed to everyone. That, rather than prolongation at any cost or a fixed cut-off, is the position that can be defended.