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Le Monde diplomatique
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July 2002
HEALTH FOR ALL OR RICHES FOR SOME
WHO's responsible?
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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 *
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"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.
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* 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
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.
Translated by Luke Sandford
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