BMJ  2003;327:111 (12 July), doi:10.1136/bmj.327.7406.111

reviews

PERSONAL VIEW

A time to ask what you want of WHO

Five years ago Dr Gro Harlem Brundtland took over a largely demoralised World Health Organization from Hiroshi Nakajima and initiated a reform to give WHO new relevance to current public health needs. Technical staff warmly welcomed the strong emphasis she placed on evidence based advocacy, openness and transparency, and unity within the organisation.

Last year it became clear that Dr Brundtland would not seek a second term and on 21 July Jong-Wook Lee will succeed her as director general. However, Dr Lee is not inheriting a reinvigorated organisation or one that is close to achieving the three overarching principles instigated by the Brundtland reform.

Dr Brundtland did succeed in getting health recognised as an issue on the global political agenda and in drawing attention to the economically debilitating effects of ill health. However, this gain may have been achieved at the expense of other priorities.

Many of the public health issues that face us today are not controversial. There are no advocates of malaria, polio, HIV/AIDS, etc, so everyone can agree to eliminate them, although there will be debate over how. Public health, however, is also contingent on less clear cut issues, particularly in the area of environment and health, where the detriment and the cause are not so obviously associated, or visible, and the balance between societal benefit and individual detriment contentious. For example, in the case of nuclear power generation, the waste disposal problem remains largely unsolved and the health effects of low dose exposure are a matter for controversy, but there is minimal contribution to global climate change. It is surely in situations such as this that a sound evidence based approach is critically important and it is here where the Brundtland reform has most crucially failed.

Decisions have been made autocratically

Two World Health Reports, in 2000 and 2002, both evidence based, have been criticised on methodological grounds. A few weeks ago, writing in the Lancet, the editor in chief of the 2000 report alleged manipulation of the evidence, and autocracy over decision making by senior management ( Lancet 2003;361: 1817-20[CrossRef][Medline]). These reports are the visible face of the failure to manage an evidence based policy; as with an iceberg, much more lies beneath the surface.

WHO's decision making on issues related to public health and ionising radiation—my area of expertise—has been dictated to a large degree by the perceived needs of the International Atomic Energy Agency. Decisions, contrary to the evidence, have been made autocratically and without transparency. For example, the effort devoted to the creation of a facility dedicated to providing public health advice in the event of nuclear emergencies—such as the detonation of a "dirty bomb"—was annulled with the closure of the Helsinki Project Office, without the provision of an alternative or a reason. The "turf war" between the European Regional Office and Geneva in the Nakajima era—for example, over responsibility for the follow up to the Chernobyl disaster—has raged unabated throughout the Brundtland term.

It is surely important that the scourges of the last century are eliminated. Dr Lee, a vaccines specialist, may well prove to be the right person for that. But what of the more insidious threats, particularly to economically developed countries, where pressures to exploit existing and new technologies commercially—for example, mobile telephones and some aspects of nanotechnology—pose potential public health risks? In the European Regional Office the in chemical safety, occupational health, wastes management, and radiation and health have been dispensed with within the last year or so following the closure of the environment and health department, once a globally respected entity. The decimation has been hardly less severe in Geneva.

Access to health through appropriately priced drugs for the world's poorest is surely a vital and worthy cause. But equally, so is the anticipation and prevention of morbidity and mortality through the exploitation of the existing and rapidly growing scientific knowledge, to say nothing of the wellbeing associated with an environment that poses no threat to health from the food we eat, the air we breathe, and the water we drink.

It is surely time to ask ourselves what we want from WHO. An organisation that retrospectively dispenses pills and counts the sick and dead is one thing; an organisation that proactively harnesses the best scientific decision making apparatus worldwide and fearlessly evaluates and confronts proposed technological innovation with sound evidence, is another. If this latter role is wanted, then a major reform of the existing senior management culture is essential. It is a matter for the member states to decide. Dr Lee's term provides the opportunity.

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department of environmental sciences, University of Kuopio, Finland 106305.2424{at}compuserve.com

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The author was employed as radiation scientist and regional adviser by the European Regional Office of WHO from September 1991 to May 2003. The views expressed are those of the author and are not necessarily those of either the University of Kuopio or WHO.

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