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Le Monde diplomatique


  July 2002


WHO's responsible?

   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.

                                       by JEAN-LOUP MOTCHANE *

    "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

    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

    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

    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.

    * Professor emeritus at Paris-VII university.

    (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 Libération, 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

    (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

    (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.


                                  Translated by Luke Sandford


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