The Brundtland Legacy
The five-year tenure of Gro Harlem Brundtland as head of the World Health Organisation (WHO) has just come to an end. She leaves behind some notable political successes, but many health failures. Her time at the helm has significantly reduced complaints, especially from America, that the organisation was hopelessly out of touch and corrupt, but at the same time she has politicised WHO, making it yet another multilateral organisation that is broadly anti-capitalist, pro-NGO, and therefore inevitably incapable of doing what the poorest of the poor require.
In 1998, the WHO was celebrating its fiftieth anniversary, and its programs were as tired as an overweight middle-aged man. Once held in high esteem for its containment of infectious diseases, it was largely seen as failing its core needy constituency--the poorest in Africa, Asia and Latin America. Not only was it inadequately addressing old problems like tuberculosis, dysentery and cholera, it was also dropping the ball when it came to new threats, too. Its AIDS programs were so abysmal that the UN established a new office, UNAIDS, to deal with that health pandemic.
Dr. Brundtland had an obvious challenge to update the organisation; many thought her up to the task. Her aim was to push health up the global political agenda, and her two top health priorities to achieve this aim were malaria and tobacco.
The former is indeed a disaster and one worthy of her attention. With over a million children dying every year from malaria, her Roll Back Malaria (RBM) program was welcomed by developing nations, especially those in Africa. She aggressively pushed insecticide treated bed nets as the core part of the WHO program and encouraged public private initiatives in drug and vaccine development. Unfortunately, her background as an environmental leader stopped her from pursuing the best method of malaria control--she was Prime Minister of Norway and was a significant part of the Green movement of the late 1980s, which lead up to climate, biodiversity and other international treaties.
The use of insecticides sprayed on the walls of dwellings to deter malarial mosquitoes is the most cost-effective method of achieving dramatic reductions in malaria, and had been the favoured method of the WHO in the 1960s and 1970s. But because insecticides can cause environmental problems--and since the main weapon historically was DDT, that totemic enemy of the Green movement--she refused to allow insecticide use to be a part of her RBM program. The impact of this policy has been dramatic. Bed nets are useful and can prevent malaria, usually resulting in about a 30 percent reduction when there is near-universal coverage in a village. But DDT will reduce numbers by over 60 percent (usually within two years), and at half the direct cost. The total savings is even more impressive since medical bills are slashed because of fewer cases and more healthy male workers, meaning increased productivity.
The impact of a DDT-free WHO was that it discouraged nations from using the chemical, costing thousands of lives and millions of dollars in less-effective alternatives. Furthermore, aid agencies take WHO policy as a guide to best practices and would also not fund DDT use. The RBM program has failed dramatically to reduce malaria, but it has increased awareness of the importance of the disease.
Brundtland's second target of tobacco was a dubious one at best. Tobacco-related diseases may kill millions of people a year, but even if one assumes that smoking is addictive and therefore people do not choose to smoke, it is still not a major killer in the poorest parts of the world. Nevertheless, it achieved what Brundtland desired. By using the same Framework Convention model that she had encouraged for climate change, she recently forced through a tobacco treaty, which has been signed by Germany and the U.S., although it is probably unconstitutional in both countries due to the demands against free commercial speech, especially restrictions on tobacco advertising.
The mischief that will follow from this convention, with lifestyle demands of Western activists becoming mainstream public health policy, is scary for all of us, but it is particularly so for alcohol and food manufacturers who see themselves as the next targets. Many commentators see the tobacco convention as a terrific achievement, and politically it certainly is. And it will reduce smoking, and hence death, around the world. But the misuse of science required to convince parties to take part was staggering. There is no good evidence that advertising increases total consumption--it does affect brand switching--and that passive smoking kills people (the relative risk, based on questionable data, of regularly inhaling someone else's smoke is lower than eating an extra cookie a day). Under Brundtland's reign, the WHO plumbed new depths of junk science, and undermined freedom in the process.
Her successor is a Korean, Lee Jong-wook, who has set AIDS as his main target. He laudably wants to treat three million Africans in a few years, trumping the two million target of President Bush. He has hired Brazilian AIDS head Paolo Teixeira, the nemesis of the drug industry, to help work out how to increase access of the poorest to AIDS drugs. But as I have mentioned in a previous column, Brazil is too rich, more diverse, and has far fewer AIDS cases than Africa to be seen as an exportable model. Teixeira's appointment may be more political than for policy input. Dr Jong-wook may have deftly shown to health activists that he will not be the patsy of the drug industry by employing Teixeira. At least I hope that is why Dr Jong-wook has employed him. If he actually intends to try to export the Brazilian model to Africa, the result will be short term success in terms of more drug access, but mid-term build-up of drug resistance, and long-run decline in new drugs as the industry leaves AIDS research when their potential profits dissipate.
The WHO is at a crossroads. It has more political clout than at any time in the past two decades, and it handled the SARS problem pretty well. But it risks pandering to activists, and the result will be doing what Western activists want, and not what the poorest need.