Can we still rely on the World Health Organisation? It has not openly opposed the greed of the major global pharmaceutical companies and its director-general, Gro Harlem Brundtland, has deferred to them.
We have to protect patent rights. We need them to ensure the
research and development will yield badly needed new tools and
technologies. We need mechanisms to prevent re-export of lower priced
drugs into richer economies. This ringing endorsement of drug
patents was not made by a multinational CEO, but by Dr Gro Harlem
Brundtland, former prime minister of Norway and WHO director-general,
at the World Economic Forum in Davos (Switzerland) on 29 January 2001.
Dr Brundtland was also full of praise for the pharmaceutical
The industry has made admirable efforts to live up to
this obligation through drug donations and limited price
reductions. In her view the pharmaceutical industry’s efforts were
all the more laudable because they were made despite
the concern of
companies that lower prices in the developing world not be used as a
lever to influence negotiations in countries that can easily afford to
pay more. Dr Brundtland made her comments with respect to
multinational morality just five weeks before 40 pharmaceutical
companies brought legal action against the South African government,
which they accused of importing generic drugs from other developing
Dr Brundtland took up her post on 13 May 1998 and wasted no time in
outlining her strategy to the WHO’s member-states at the 51st World
Health Assembly, where she insisted that WHO projects must be
for our partners to co-sponsor. But which partners? Primarily the
private sector, which was offered a role, together with the primary
multinational organisations, including the World Bank, the
International Monetary Fund and the World Trade Organisation (WTO).
Dr David Nabarro, executive director at Dr Brundtland’s office,
justifies the director-general’s chosen course of action:
certainly need private financing. For the past decade governments’
financial contributions have dwindled. The main sources of funding are
the private sector and the financial markets. And since the American
economy is the world’s richest, we must make the WHO attractive to the
United States and the financial markets.
Presented as a statement of genuine need, the belief that the WHO
should submit to the dictates of Washington and global liberalisation
while seeking charity from the large institutions is a matter of
ideology, since private-sector contributions account for a tiny
fraction of the organisation’s resources. A diplomat with extensive
experience with UN institutions confirms this point:
Brundtland’s stance with respect to the pharmaceutical industry stems
from her faith in the current globalisation process. Having already
established closer ties with the WTO, she is now reiterating the
positions of the World Bank, the WHO’s main financial sponsor. If the
director-general adopted a different position, she would be pitting
herself against the US, which has a dominant role. Policy
The WHO held its fourth Ministerial Conference in November 2001 in Doha (Qatar). Developing countries with pharmaceutical industries won the right to make cheaper copies of patent-protected drugs, but only in the event of public health emergencies; and they are not authorised to re-export these drugs to poor countries unable to produce the drugs themselves. This qualified victory was won without the help of the organisation’s top leadership, despite the courageous stand taken by some WHO representatives (1). It had more to do with the weight of public opinion and the educational efforts of various non-governmental organisations (NGOs), not to mention a spectacular policy reversal by the US.
Following the 11 September attacks, the US took on the German company Bayer, which produces Cipro, the anti-anthrax antibiotic. It told Bayer that it would start producing the drug itself if the company failed to offer the US a substantial discount. Resorting to blackmail made it difficult for the US to oppose other countries that advocated the primacy of healthcare rights over patent rights.
Although the WHO hierarchy had little to do with this development, on 17 May 2002 the 55th World Health Assembly unanimously approved—with US support—a resolution regarding access to essential drugs. The resolution called on the WHO director-general to take all steps to promote a worldwide policy of differentiated prices for essential drugs.
As a result of lobbying by numerous delegations—and because the WHO no longer had any reason to fear Washington—Dr Brundtland’s organisation has finally taken on an active role with respect to drugs access, in contrast to its earlier perceived spinelessness.
Though such policy flaws predate Dr Brundtland’s appointment, they
prompted the UN to launch the Joint United Nations Programme on
HIV/Aids (UNAIDS) in 1996 to coordinate the global fight against
Aids. The executive director of UNAIDS, Dr Peter Piot, took a very
different stance from the WHO. On 29 November 2000, prior to the legal
proceedings in South Africa, Dr Piot declared that he fully supported
the rights of governments to pursue compulsory licensing (2) and
parallel importing, along with competition between generic and
patented drugs. He said boldly:
The rules of the liberal economy
have become incompatible with the globalisation of the Aids
epidemic. We now need a new deal between drug companies and
But the rules of the liberal economy govern current WHO policy
considerations. In 1980 Halfdan Mahler, then the WHO director-general,
made the Health for All initiative part of official development
assistance policy. This rallying cry is only occasionally invoked
nowadays, since Dr Brundtland—at least in her public statements
- sees access to healthcare not as a right but as a means to increase
productivity. In a recent speech to a group of business leaders,
bankers and heads of state, she stated that
good health is
essential—to fuel the engine of development, to unleash the
forces of economic development and to permit the reduction of
poverty (4). Seeking to convince her audience of the need for
investment in healthcare, she also drew attention to disease’s
negative effects on economic growth: according to some estimates Aids
will reduce annual gross domestic product (GDP) by 1% in the hardest
hit regions. Within 30 years the malaria epidemic will have brought
about a $100bn drop in productivity in Africa.
One banker offered this reaction to Dr Brundtland’s speech:
helpful, even crucial, to calculate the cost of disease and the
resultant loss of earnings. Health is clearly a factor in
development. Bismarck knew that in the late 19th century. He was the
first to persuade management to create a mutual health insurance
system for workers so the factories could go on running. But it is
naïve to think that business people will be persuaded to invest in
healthcare in a globalised labour market.
On 17 May 2001 the UN secretary-general, Kofi Annan, who is also facing re-election, muscled in on Dr Brundtland’s turf when he called for the creation of the Global Fund to fight Aids, tuberculosis and malaria, with an annual budget of $7bn-$10bn. Annan’s intervention was made possible by the WHO’s failure to obtain convincing results in the fight against infectious diseases. But despite promises by the Group of Eight nations at their conference in Genoa in July 2001 to grant the Global Fund $1.3bn, it has only received $200m to date. This contrasts starkly with the $1.9bn pledged by various donors or the $1.6bn already allocated by other donors to comparable programmes (5). Conflict of interest
The creation of the Global Fund was originally seen as an important step forward, but its status as an independent foundation governed by private law (6) means that the UN will no longer be responsible for a key component of global health policy. The WHO’s role is negligible and, with the creation of UNAIDS, the WHO has been further marginalised in a field that at one time was its raison d’être.
Many people have complained about Dr Brundtland’s subservient
policies. In an open letter to her (8), Ralph Nader, while recognising
her efforts in combating malaria, tuberculosis, smoking and the
tobacco industry, said:
Many are concerned that the World Health
Organisation has permitted a handful of large pharmaceutical companies
to exercise undue influence over its polices and programmes. The WHO
has shrunk from its traditional role in promoting the use of generic
drugs in poor countries. Dr Brundtland refuted these charges in
her response to Nader’s letter, saying she had had worked to
strengthen the WHO’s international credibility and to put health
issues at the top of the agenda of global development policies.
One of Dr Brundtland’s colleagues, Daphne A Fresle, recently submitted
her resignation from the WHO in a letter that amounted to a scathing
indictment of the organisation and its director-general (9). Ms Fresle
the lack of enthusiasm shown by the current
administration in publicly defending the developing nations’ vital
interests, which should be the organisation’s primary
consideration. According to Ms Fresle, the WHO has abandoned its
traditional goal of Health for All and now serves the interests of the
most powerful countries and of the pharmaceutical companies. Owing to
their lack of scientific rigour, she says the organisation’s latest
reports have harmed its credibility and reputation (10), and the WHO’s
administrative reorganisation has been a failure (11). The WHO’s
policies over the last three years had had two main consequences: the
WHO was facing ethics-related accusations and had squandered its
leadership role in the health field as a result of the Global Fund
At the WHO’s enormous headquarters in Geneva many people we spoke with
discreetly confirmed that they shared these views. One bureaucrat, who
is critical of the Global Fund, commented:
its shortcomings—the WHO allowed the 191 member-states to make
their voices heard at the World Health Assembly. From now any new
steps to fight the three most important infectious diseases will hinge
on the virtually secret deliberations of a private foundation, whose
executive board has no real accountability to the international
For one high-ranking official who has served under several
directors-general, the WHO is at a crossroads. In his opinion, the
organisation must clearly redefine its mission in the light of
globalisation and the competing interests of governments, individuals
and the private sector (13).
Countries or regions should call on
the WHO to put together global health guidelines, in which all parties
concerned may clearly state their expectations with respect to global
health policy. It seems that no one any longer knows exactly why
the WHO exists. But growing numbers of observers believe that the
current trend towards privatisation of the global health system will
only serve to exacerbate existing inequalities.
(1) These representatives include Colombia’s German Velasquez, one of the WHO’s leading experts on essential drugs and is a noted defender of the rights of sick people in poor countries. He was assaulted on 26 May 2001 in Rio de Janeiro and two days later in Miami. His attackers referred to his criticisms of the pharmaceutical companies’ patent policies.
(2) Compulsory licensing is provided for in Article 31 of the WHO’s
agreement on trade-related aspects of intellectual property rights
(Trips). Governments facing health emergencies are authorised to issue
operating licences relating to patents without obtaining the
permission of the patent-holders. See Philippe Demenet,
cost of living, Le Monde diplomatique English edition, February
(3) See Libration, 5 March 2001.
Why Invest in Health, Dr Brundtland’s speech to the Third
International Conference on Priorities in Health Care held in
Amsterdam, 23 November 2000.
(5) Le Monde, 27 April 2002. See also Philippe Rivière,
wrong, Le Monde diplomatique English edition, July 2001.
(6) The Global Fund was designed as a partnership between governments, private organisations, civil society and international institutions. Its executive council includes seven representatives from donor countries, seven from developing countries, two from the private sector and two from NGOs. The private-sector organisations are the Bill and Melinda Gates Foundation and Anglo-American PLC (a global leader in the mining and natural resources sectors). UNAIDS, the WHO and the World Bank have non-voting representatives. As the manager of the funds raised, the World Bank has an important responsibility.
(7) See the WHO website, Thomas Zeltner et al.,
Strategies to Undermine Tobacco Control Activities at the World Health
Organisation, a report by the Expert Committee on tobacco industry
documents, Geneva, July 2000.
(8) Ralph Nader, letter dated 23 July 2001.
(9) Letter from Daphne A Fresle to Dr Brundtland, 23 December 2001, Geneva. Ms Fresle worked in the WHO’s Department of Essential Drugs and Medicines Policy.
(10) See World Health Report 2000,
Health Systems: Improving
Performance, Geneva, 2001. The report contains a listing of the
healthcare systems in the various member-states, and ranks them in
terms of efficiency. The report’s statistical methodology and the
absence of reliable data have met with harsh criticism. See Cella
Almeida et al,
Methodological Concerns and Recommendations on
Policy Consequences of the World Health Report 2000, The Lancet,
Vol 357, London, 26 May 2001.
(11) The WHO’s audit with respect to reorganisation has not yet been made public.
(12) Richard Horton,
WHO: the casualties and compromises of
renewal, The Lancet, Vol 359, Issue 9317, London, 26 May 2001.
(13) The WHO’s relations with the private sector also involve the rich nations. The WHO sets a wide variety of international standards governing such things as nitrate levels in drinking water; sulphur levels in the atmosphere; dioxin levels near garbage incinerators; the power capacity of cell phones; and healthcare for the mentally ill.