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Health for all or riches for some: WHO's responsible?

By Jean-Loup Motchane, Le Monde diplomatique, July 2002

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 companies: 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 countries.

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 open 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: We 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: Dr 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 reversed

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 society (3).

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: It is 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 condemned 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 (12).

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: In theory—despite 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 community.

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, The high cost of living, Le Monde diplomatique English edition, February 2002

(3) See Libration, 5 March 2001.

(4) 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, Patently 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., Tobacco Industry 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.