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EDUCATION AND DEBATE: Gavin Yamey WHO in 2002: Why does the world still need WHO? BMJ 2002; 325: 1294-1298 [Full text]

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WHO needs chaos and complexity science?

Vivian S Rambihar   (1 December 2002)

Should WHO confine its activities to monitoring??

Richard G Fiddian-Green, Formerly Professor Chair General Surgery University Massachusetts   (11 December 2002)

The world needs the WHO, a different WHO

Guillermo Arturo Herrera Taracena   (19 December 2002)

WHO needs chaos and complexity science? 1 December 2002
Vivian S Rambihar, Cardiologist, The Scarborough Hospital. 3000 Lawrence Ave, E, #3302. Toronto, Ont, Canada.M1P 2V1. Send response to journal: Re: WHO needs chaos and complexity science?	WHO needs chaos and complexity science? In the revealing series of articles on WHO, Gavin Yamey makes a strong argument for its value as an overarching agency, important to the health of the world’s people (1). He noted, however, that its management was fossilized, and that a team of consultants regarded its management reforms as "the worst of both worlds" (2). In discussing overcoming hurdles in its reform process, he suggests that it should provide evidence based and trustworthy guidance to a globalised world (1). The WHO can be revitalized and rejuvenated by chaos and complexity science, over 300 years in the making, and now fortuitously available, offering new perspectives, innovative ideas and tools for desirable change (3). As a new basic, organizational, management and leadership science, with features that include those thought to be desirable by Yamey – a structure that devolves resources to country level and a culture of greater openness and debate, it should have much to offer. By using chaos and complexity ideas - diversity of opinions, more decentralization and autonomy with fewer rules, self-organization and emergence of ideas, feedback, interaction and responsiveness, the power of leverage from sensitive dependence and more anticipation rather than reaction, we can have the best of both worlds (3). As a global organization with diverse and competing interests, WHO may benefit from the ensuing fractal vision approach to world problems and their solutions, where local context and dynamics shape local practice, yet keeping true to the central mission and guiding principles of the organization. Cohesion, without regimentation could be provided by chaos and complexity, overcoming the fragmentation caused by globalization noted by Yamey. Newer models of practice derived from chaos and complexity would reflect the new challenges we face living in a Fractal World where fractal patterns of health, disease, organization and everything else now emerge everywhere, taking us away from the Global Village we once lived in. A new evidence based approach in context can become the best practice for health and policy, using the new science of chaos and complexity as the new science base (3,4). These ideas (a discussion on its theoretical base "A new mathematical (chaos and complexity) theory of medicine health and disease: refiguring medical thought," available at <http://www.complexityprimarycare.org/Rambihar.PDF>) have been used successfully in various projects at a smaller scale (5), and should be explored by WHO, since it seems WHO does need chaos and complexity. References: 1. Yamey G. WHO in 2002: Why does the world still need WHO? BMJ 2002; 325:1294-1298. 2. Yamey G. WHO in 2002: Who’s management struggling to transform a “fossilized bureaucracy. BMJ 2002; 325:1170-1173. 3. Rambihar VS. A New Chaos Based Medicine beyond 2000: the response to evidence. Toronto: Vashna Publications, 2000. 4. Rambihar VS. Science, evidence and the use of the word “scientific. Lancet 2000; 355:1730. 5. Rambihar VS. Organizing with Chaos…the new management science in Chaos 2000: From Cos to Cosmos: Making a New Medicine for a New Millennium. Toronto: Vashna Publications, 1996, 2000. Competing interests:   None declared
Should WHO confine its activities to monitoring?? 11 December 2002
Richard G Fiddian-Green, None None, Formerly Professor Chair General Surgery University Massachusetts Send response to journal: Re: Should WHO confine its activities to monitoring??	Surely the greatest threat to humanity today is the exponential growth in the population, its accompanying demand for food and energy from the burning of fossil fuels, loss of habitat and pollution of ground water and oceans. If so acting “at a global level to co-ordinate the disparate activities in health, and at the country level to ensure that the poorest people benefit the most from the latest injection of health funds” is not the most rational way for WHO to proceed (1). There is no sense in WHO giving people in lesser developed countries jobs, saving lives by promoting the growth of genetically enhanced crops or distributing food to the starving, distributing vaccines, or even regaining control over malaria without addressing these concerns. In so doing WHO will simply compound the magnitude of the problems by accelerating the growth in population, its accompanying host of illegitimate, abandoned and malnourished children, and its demand for energy, clean water and other diminishing resources. One of the best contributions WHO has made under Brundtland's leadership has been defining and measuring longevity and disability- adjusted longevity in different countries as reported in the Economist and elsewhere. The reliability of the data gathered concerning the number of deaths from starvation, violence, malaria and especially “AIDS” in lesser developed countries and especially in Southern Africa is, however, highly questionable. Should not the primary objective of WHO be to set in place systems for gathering much more reliable and comprehensive data on human and environmental health with which to make accurate predictions of impending catastrophes, notably the time left to avert a decline in cognitive abilities and increase in birth defects caused by pollutants and mass extinction from overpopulation, environmental degradation and pollution, and to monitor the success or failure of the interventions chosen to address them. Furthermore should not WHO not make better use of its resources and networks by using them to identify incentives that make people in all countries change their habits sufficiently to address these problems in a timely manner? One lesson learned in recent decades is that setting targets and goals and handing out grants to lesser developed countries does not work as effectively, efficiently or cost-effectively in implementing desirable changes in a timely manner as innovative solutions stimulated by monetary incentives and driven by free market means. In looking for someone to replace Brundtland and her team perhaps WHO should perhaps reconsider its mission and in so doing consider appointing someone with the statistical skills needed to identify and address the problems confronting personal and environmental health by free market means. Credible candidates for leadership or inclusion in such an effort might include Knauss from Washington, Khuri from Boston, le Gall from France, and Miranda from the Netherlands. 1. Yamey G. WHO in 2002: Why does the world still need WHO? BMJ 2002; 325: 1294-1298. Competing interests:   None declared
The world needs the WHO, a different WHO 19 December 2002
Guillermo Arturo Herrera Taracena, Idependent Medical Epidemiologist ECOS, Epidemiology Consultancy Service, Ozvatan Sokak 17-2, Teras Evler, Cankaya, Ankara, Turkey. Send response to journal: Re: The world needs the WHO, a different WHO	Editor, The challenges we face and the choices we make shape the world we live in and the world we would like to have. There are greater opportunities today than fifty years ago and technologically and scientifically we have advanced to uncharted terrain. Genetic therapy is now a reality and cloning, for whatever good and evil it will bring, is around the corner. However, everywhere we turn our eyes to, we can find gender, wealth, knowledge, and social inequalities. These inequalities are the defining issues in terms of health; if there is inequality there is suffering, and wherever there is suffering, the soul and the body are in pain and prone to disease. At the personal level, we human beings are looking for understanding, respect, reciprocity, honesty, and commitment. We want to be listened and to be taken into account as equals, to be able to contribute and work for a common destiny as member of the same human race with equal rights and responsibilities. We want to be given the opportunity to act locally and apply local technology when resources available are scarce and be able to contribute globally what we have learnt locally through centuries of innovation and hard work. We are asking for paternalistic attitudes to stop and for rich countries to realize that there is wisdom in humility and knowledge in nature. We refuse to become human subjects, as we are human beings, of research that would ultimately benefit the rich nor do we want to find our natural remedies been patented and out of reach. At the global level, we want to share in wisdom and knowledge with the world. We want for the developed countries to realize that the solutions to the problems in our developing world are to be found within the developing world: utilizing our strengths, developing our human resources and infrastructure, and fighting inequalities. It does not make sense to send armies of experts and consultants who are not invested and are, many times, not culturally aware or do not speak the language, to solve problems they intellectually understand but have not lived socially and physically. We value good intentions but we would prefer to see programs and interventions that are viable in the short as well as in the long term. At the global level we want to see accountability and sustainability. Our global community deserves a World Health Organization that can represent us equally. An organization where the North and the South, the East and the West can meet, share, discuss our common problems and finds solutions addressing health and structural issues as well as the inequalities behind the health problems. We need sustainable interventions that take into account the voices, experiences and utilize the strengths of the countries and communities the WHO is supposed to be serving. We do not want to see the same recurring emergencies because long term and sustainable initiatives based on community participation and ownership were never carried out. How many more famines, epidemics, or unnecessary measles deaths? Is it impossible to develop adequate infrastructure and housing to fight malaria instead of only providing impregnated bed nets? When is the WHO, UNICEF, UNFPA, World Bank, etc., going to start working together as a team and stop turf fighting at the expenses of the developing world? To do so, the WHO needs to be visionary, democratic, flexible, inclusive, and accountable. Visionary to undertake the difficult and courageous task of disease elimination against appeals not to do so because of the threat of biological warfare; democratic, electing its own high and middle ranking officers through external and internal open and democratic processes where experience, capacity, commitment, vision, honesty, impartiality count much more than political convenience; flexible, so that disease prevention theory can coexist with social and economic development and real dialogue and cooperation can start among the United Nations agencies; inclusive, by giving way to balanced and equal representation and power to countries and regions of the world within the organization instead of an institution where the western mentality and culture dominate and impose decision making; accountable, where success is measured on sustainability and community ownership instead of the number of heads trained or wells drilled. The world needs a WHO, but a different WHO from what we have today. Competing interests:   None declared