TWN Info Service on Health Issues (May15/02)
18 May 2015
Third World Network

Dear friends and colleagues,

We are pleased to share with you an article by German Velasquez titled "WHO: An Organization Adrift - Will the World Health Organization survive the Ebola epidemic?", first published in the May 2015 issue of Le Monde Diplomatique. The original article is in Spanish and below is the unofficial translation.

The author is Special Adviser for Health and Development of South Centre, a think tank of developing countries. Before that he was a senior WHO official, well known for his groundbreaking work on intellectual property and access to medicines.

With best wishes,
Third World Network

Will the World Health Organization survive the Ebola epidemic?

By Germแn Velแsquez (1)

If we would had to do a caricature of the UN specialized agency, the World Health Organization (WHO), it would look like an old woman who is only 65 years old but looks more than 90 years old... with sunglasses for having almost completely lost her sight, and in a wheelchair pushed by Bill Gates on one side and the manager of a large pharmaceutical company on the other... The old woman in the wheelchair delivers a speech to a large army of young health professionals working in Geneva, not in Guinea, or Sierra Leone or Liberia, to combat the epidemic of Ebola ...

The WHO, the United Nations specialized agency for health, is slowly dying, in the eyes of the international community which is divided among promoters, accomplices and observers of the disaster.

In the management of avian flu H5N1 (2005) at least two flaws, among many others, can be identified: In August 2005 the Executive Director of the WHO Director-General’s office announced in a press release that 150 million people could die of this global epidemic. Five years later the WHO reported total deaths due to avian flu H5N1 of 331 people, concentrated mainly in Indonesia and Vietnam.(2)  Between 150 million and 331 deaths, the least we could point is the lack of rigor in epidemiological forecasts. The second flaw in relation to avian flu was the enormous waste of security stocks of the drug oseltamivir (known under the brand name "tamiflu"). Never in the history of medicine were there stocks of a drug whose effectiveness was not known, for a disease that had not yet come and that never came. Some years later the scientific community proved that, in addition to the resistance created by the drug’s overuse, it had no efficacy. The quantities stored were gigantic, for 25% of the population in Canada, 25% in the USA, 25% in the UK, 50% in France and other European countries, 23% in Japan.(3)

In 2009-2011 with the H1N1 flu outbreak, WHO launched a new alarm, and contrary to the view  of international recognized experts, WHO declared the highest global pandemic phase. This disease with very rapid transmission had however a very low mortality, while about 500,000 people die each year from the normal seasonal flu.  WHO reported only 18,449 deaths over a period of two years for H1N1. The highest pandemic phase enabled the vast majority of industrialized countries, with WHO recommendation, to buy several million vaccines, from which 90% had to be incinerated because they were not used. France, for example, with a population of 66 million people, bought 94 million doses, of which only 6 million were used. Waste from France were of the same proportions as in the USA, Germany, Belgium, Spain, Italy, the Netherlands and Switzerland, with the purchase of vaccines and again, with the stocks of oseltamivir.

It seems that little has been learned from past mistakes. In the management of Ebola (2014-2015) the outbreak was announced in March 2014 by Doctors Without Borders (MSF) and WHO began to act only in July / August of the same year ... a delay of 4 months which was maybe one of the causes of the outbreak reaching dimensions of a global threat. Ebola is a type of hemorrhagic fever that first appeared in Zaire in 1976, almost 40 years ago. In previous periodic outbreaks an average of 300 deaths per year had been reported.

On January 25, 2015, WHO reported 20,689 cases and about 8,626 deaths, mainly in Sierra Leone, Liberia and Guinea. Why this significant jump in the number of cases? The delay to start treating this outbreak can be one cause, but surely not the only one. In all documents produced by WHO in the past eight months, no one asked about the causes of the disease, and especially  the drastic increase in the number of cases… WHO's priority is to raise funds and make clinical trials for the vaccine already in the hands of the American and Canadian army for the last 10 years.
Some ongoing studies (4) seem to suggest that one of the main causes could be massive deforestation, for agriculture and mining, which have changed the balance between the forest animals and man.

This outbreak, which is now dying, may come back stronger, if the possible causes are not studied and if efforts are limited to raising funds to build health infrastructure ant to store vaccines. The WHO plan also foresees the training of health personnel. However, the "brain drain"  what David Sanders prefers to call “brain robbery”  is unfortunately not mentioned in the WHO draft resolution that will be presented for adoption by the World Assembly Health in May this year. There are more doctors from Sierra Leone working in OECD countries than in their own country.(5)

WHO announced in January 2015 "reforms" to better prepare for future epidemics. However, the causes and the roots of the problem have not been addressed - causes that are probably associated with environmental damage due to the massive exploitation of minerals by foreign companies.

In the case of Sierra Leone the rapidly expanding industry of iron ore mining led to an economic growth of 20 percent last year, according to IMF data. The interest in untapped mineral resources has sparked a flood of investment. Its economic growth rate is among the highest in the world.
This exceptional economic growth appears not to be benefiting the national economy. Tax evasion is one of the main causes of revenue losses, especially in the mining sector in Sierra Leone. In 2010 the country's mining industry contributed nearly 60% of exports, but only 8% of government revenues. Of the five major mining companies in Sierra Leone, only one is currently paying taxes.(6)

If the country had benefited from this "economic boon", at least they could have built some health infrastructure to address this epidemic. These are not the social and economic determinants of health which WHO speaks of. It is a pity that the resolution to be presented to the World Health Assembly in May 2015 has "forgotten" to mention this aspect.

In managing Ebola, in addition to the delay in reaction, there are scandalous dimensions from an ethical point of view. An epidemic that has been known for 40 years, WHO and the media announced that the army of USA and Canada have for ten years a vaccine to protect themselves in case of biological attack ... but not to save the lives of the poor in Africa. This proves once again the failure of the current model of R & D of pharmaceutical products where innovation works for purchasing power rather than the frequency of the disease.

As on other occasions, the WHO argues that it is a problem of lack of funds to address the epidemic of Ebola, which may have some truth, but the problem is not financial but structural. What is at stake is the ability of the agency to respond to such problems. The answers are slow, the recommendations are not always clear and enforcement mechanisms of implementation of  strategies and action plans are almost nonexistent.

In national health contexts, deficiencies in managing such problems often lead to the resignation of the Ministers of Health. In the case of WHO, will the Director-General be the only person "vaccinated" against Ebola?

Parallel to repeated failure in handling health problems worldwide, and led by some industrialized countries with the complicity of the WHO Secretariat, a progressive privatization of the agency has occurred. Eight years ago, the WHO had a budget with at least 50% of public funds constituted by mandatory contributions from member countries, but now it only constitutes 20%. The agency is currently in the hands (80% of their budget) of philanthropic foundations like Bill and Melinda Gates, a small number of industrialized countries that offer some voluntary contributions and the  pharmaceutical industry. The vertiginous loss of control of the budget leads to inability to set priorities. The member states in a slow rhetoric try to set priorities, but the funds come from the private sector for specific topics, set by private and public donors, new owners of the organization ...

Improvisation, delays, lack of independence and conflict of interest lead unsurprisingly, WHO to a loss of credibility. The funds for health available in the international community are beginning to be used for other bodies such as the Global Fund, UNITAID, UNAIDS, UNDP, PEPFAR. And now, in the debate about the delay of the WHO to intervene, some suggest the need for a new agency that can respond to global health emergencies.

Suddenly we find ourselves today with that public multilateral agency that has become a cumbersome bureaucracy, with excess staff of about 3,000 in Geneva (when the WTO has under 600), with serious financial problems and an overall disruption in the hierarchical structure of power between headquarters in Geneva and six fully independent regional offices, which do not report to the Director-General but to the Ministers of Health of each region, who elect and re-elect the Regional Directors ... the power relations between the operational arm which are over 150 country offices, which do not report to the regional offices or headquarters but, for some reason, to the Minister of Health of each country ... make the Organization an army without central command, unable to respond timely and effectively to problems such as avian flu or pandemic H1N1 or Ebola which currently exists..

Gro Harlem Brundtland, Director-General of WHO from 1998 to 2003, threw the expression, fashion today, "health diplomacy". Diplomacy has been very useful for finding solutions for border conflicts, or military problems, or any kind of disputes that can reach negotiated agreements where different parties give up only little. In public health and medical care where there is scientific evidence for something, "prescription" is not negotiable. A drug dose less than needed will be useless while an excess dosage can become poison and kill the patient.

In WHO currently there are several issues in the hands of health diplomacy, negotiated by the diplomats of the missions in Geneva such as: the quality of medicines, how to fund research and development of pharmaceuticals, nutrition or even how to address the problem of Ebola.

The mode of operation of the governing bodies of WHO (Executive Board –EB- composed of representatives of 34 countries (now representatives of governments and not independent experts as in the past) and the World Health Assembly -WHA- (composed of Health Ministers and delegations from 193 member countries) is totally obsolete. Delegates spend three annual meetings (two Executive Boards and one WHA) discussing details and language of resolutions that in the end reach agreement in complicated diplomatic arrangements. WHO does not have, or rather does not use,(7) mechanisms for the implementation of the decisions that could be made based on technical evidence. Article 19 of the constitution which gives the WHO the authority to negotiate binding treaties and measures, has been used only once in 65 years. The US and the EU reject any kind of decisions that are binding on the states. How do we prevent the world from running out of antibiotics because of the growing resistance in all parts of the world? Resistance caused largely by the widespread use of antibiotics in animals prophylactically which gets transferred to human food, increasing resistance to existing antibiotics which are relatively few today. To recommend, or legislate this is the dilemma.

Until 1998 the WHO was relatively unaffected by the influence of the private sector and the public regular budget contributions of the member countries represented more than 50%. In her first speech to the World Health Assembly, Gro Harlem Brundtland (1998) said "We have to go find the private sector (...) The private sector has an important role to play both in technology development and the provision of service." (8)

During the five years of the Brundtland administration, PPPs and later product development partnerships (PDPs), grew and developed without any control or clear rules. It was a "win-win situation"  operation and that there were risks or possible negative effects were not considered, because little were controlled and the rules were not always clear. Today the pharmaceutical industry and philanthropic foundations participate in meetings of experts on various topics and are members of the board of most PPPs and PDPs.

The PPPs were so heavily promoted that the WHO itself is now a large PPP. And the owners of 80% of the budget demand more power and participation in decision-making. This debate that has been going on for three years, was discussed by the Executive Board in January 2015 and will be discussed once again at the World Health Assembly in May 2015, with the title: "Framework of engagement with non-State actors".

The fundamental starting point for any reform of the WHO should be how to regain the public and multilateral character of the institution.

The dilemma for the member countries of the WHO is clear. They will have to choose between: a PPP to manage projects funded by the philanthropic and private sector, or rebuild a public International Agency, independently steering the health sector.

1.  Special Advisor on Health and Development, South Centre, Geneva, Switzerland.
2.   Velasquez, G., “The management of A (H1N1) pandemic : an alternative view”. Journal of health law, Vol. 13 No. 2, Oct. 2012, Sau Paulo, pp. 108 – 122.
3.  Idem, p. 125.
4.  David Sanders & Amit Sengupta, “Ebola Virus Disease: What’s the primary pathology?”, Presentation at the “Prince Mahidol Award Conference”, Bangkok, January 2015.
6.  David Sanders & Amit Sengupta, “Ebola Virus Disease: What’s the primary pathology?”, Presentation at the “Prince Mahidol Award Conference”, Bangkok, January 2015.
7.  In 65 years , Article 19 of the WHO Constitution which gives the power to the WHO to negotiate treaties or agreements of a binding nature has been used only once, in the Tobacco Convention, with the efficiency we already know.
8.  Gro Harlem Brundtland speech to the Fifty-first World Health Assembly, doc. A51/DIV/6, 13 May 1998, pp. 4-5.