A global health fund: a leap of faith?BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7305.152 (Published 21 July 2001) Cite this as: BMJ 2001;323:152
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The Global Health Fund: a global bluff
Former President of G8 health experts group
Correspondence to: email@example.com
Though expressing some serious doubts, Ruarì Brugha and Gill Walt in
their article on the BMJ (2001; 323:152-154), conclude substantially
approving the launch of a Global Health Fund at the G8 summit in Genoa
They applaud the idea that – thanks to the Fund – Malaria, Tuberculosis
and HIV “are finally receiving the degree of attention they deserve”,
recognise “goodwill and commitment” behind the G8-Annan initiative and
consider “good governance” as the first step to be achieved.
Regarding governance of the fund, it is peculiar that the UN Secretary
General himself in promoting the idea of a Global Fund underlined that it
should be "governed by an independent board", and external to the UN
"because I want it to attract others to join the fight".
One may ask: Why an “independent” board to decide about the use of
resources for public global health and not WHO which has the mandate and
the legitimacy for it? Why shouldn’t resources be collected and
administered by existing UN organisations? Growing “external” interests
are evidently pushing to delegitimate the UN system (though undoubtedly to
be reformed in terms of democracy and efficiency) and to gain control of
significant spaces of global governance, while the G8 governments – not
willing to contrast those interests, and being in some cases their direct
expression - seem to be supportive of a UN role reduced only to a forum
for debate and advocacy, with relevant “global” decisions taken some where
else. It is sad to realise that UN leaders themselves, accept or even
promote that view. In any case, no UN representative would have
legitimacy to represent members states collective interests, in a board
where some of those countries autonomously represent themselves. Without
considering that rich countries’ view will already be strongly represented
in the board by the World Bank, in whose hands will be also the management
of the Fund.
Do Brugha and Walt really think that “good governance” of the
global fund may at all be possible with an evident conflict of interests
determined by the presence of a representative of industry (including
pharmaceutical, as it is stated in the G8 Presidency document) sitting in
a board which may decide about drug purchasing strategies?
About “goodwill and commitment”, it is hardly to be found with: G8
countries’ ODA at a poor 0.2% of their GNP, compared with the 0.7% target
agreed upon since over two decades; a high probability that resources they
will destine to the Global Fund will not at all be additional to existing
flows and a declared initial commitment to the Global Fund of only US$ 200
millions per G8 country, where the minimum need to face HIV/AIDS alone is
considered to be US$ 7 billions (UN estimates).
On the other side, there has been no commitment to correct macroeconomic
factors that have been causing growing inequalities and avoid policies
that may have secondary negative effects on health (as it has been the
case with Structural Adjustment Programmes), whereas only such a
preventive approach could ensure long term sustainability to any
Finally the fact that three important communicable diseases receive
specific attention (in the sense of earmarked resources, possibly even in
competition with the existing “plethora of recent global public-private
partnerships”), could just be another step to definitely abandon the idea
that health “is not only absence of disease”, for a new era of vertical,
undemocratic, unsustainable, centrally determined, donor and – now -
profit driven programmes.
Competing interests: No competing interests
FRAMEWORK CONVENTION ON TOBACCO CONTROL (FCTC): The way out
Throughout the world around 4 million people die from tobacco-related
illness each year. This is the equivalent of twenty-seven 747 aeroplanes
full of passengers crashing every day. By the year 2030, 10 million people
will die each year from tobacco use1.
Approximately 80000 to 100000 young people around the world become
addicted to tobacco each year2. Many of tobacco's future victims are
today's children. If current trends continue, 250 million of them will
eventually die from tobacco-related disease.
The future consequences are frightening. Based on current smoking
trends, tobacco will soon become the leading cause of death worldwide,
causing more deaths than HIV, maternal mortality, automobile accidents,
homidic and suicide combined3.
From all we know about tobacco two undisputed facts emerge:
* Tobacco kills
* It is a global problem
Therefore (i) the killer must be killed and (ii) the global problem
must be solved globally.
FCTC enunciated by the WHO under the direction of Dr Gro Harlem
Brundtland will promote a coordinated international response to one of the
most deadly epidemics of our time. WHO has initiated negotiations on FCTC
in October 2000. A Framework Convention is a type of multilateral treaty,
which allows states to proceed incrementally by establishing first general
framework. This is followed by specific protocols. Tobacco is truly a
global problem and a global killer.
Actions against tobacco all over the world range from legislation to
litigation. Restriction of production and sale of tobacco to minors,
limitations of smoking in public places, warning signs, publicity and
propaganda effectively implemented in the developed countries through law
enforcing authorities results in success ranging from minor effects to
In developing countries like Bangladesh regulation and legislation
are not difficult to formulate and even enactment is not impossible, but
implementation is very difficult. The law enforcing authorities are weak,
morally and ethically. They are purchasable and the tobacco companies are
always ready to give small gifts or even costly helicopters. Alluring
advertisements with glamorous models easily tempt young people to take up
smoking. Concerts and sports are also fully utilized for the young adults
and teenagers who take up cigarettes as a symbol of their personality and
Although it is not easy to fight against the tobacco industry, some
basic facts about tobacco cannot be challenged:
* As long as there is tobacco there will be tobacco users
* The tobacco industry will not easily give up
* There would be no tobacco consumers if there were no tobacco.
The ultimate solution therefore lies in tobacco elimination rather
FCTC has a moral responsibility to find ways and means to eliminate
the availability of tobacco. America, Britain and Japan have the largest
tobacco companies. If they join hands and decide to eliminate tobacco the
task should not be too difficult. Bold steps by political leaders for the
elimination of nuclear weapons have proved quite successful. If it is
possible to eliminate nuclear weapons there is no reason why we cannot
eliminate tobacco use. If the major powers make a determined effort it is
possible to create a tobacco free society. In FCTC we believe that we are
seeing the beginning of that great end. The Director General of WHO should
not be alone in her efforts. Every government has a moral and ethical
responsibility to safeguard the health of their people. Non-government
organizations need to come forward and encourage their respective
governments to join with FCTC. Working together we can certainly win the
battle against tobacco - the greatest silent killer of mankind.
The FCTC convention opens the door to a tobacco-free world.
N Islam D.Sc, FRCP, FRCPE
1. World Health Organization, NOTE TO TEK, World Health Report,
2. World Bank, Curbing the Epidemic: Governments and the Economics of
Tobacco Control. Washington: World Bank, 1999
3. Howard Barnum. The economic burden of the global trade in tobacco.
In:Slama K, ed. 9th World Conference on Tobacco and Health, October 1994,
London:Plenum Press, 1995.
Competing interests: No competing interests
The decision by the most industrialised countries (G8) to set up the
Global Health Fund shows that they are at last ready to assume moral and
political leadership in addressing the health needs of the poorest
nations, particularly those in Africa. By targetting HIV/AIDS, malaria and
tuberculosis, they have shown unique understanding of what must be done to
rescue poor nations from a potential health and economic catastrophe. I
thank the G8 most sincerely for their magnanimity, and hope that the
funding will be sustained for long enough to ensure success in the
shortest possible time.
The GAVI proposals for supporting immunisation programmes is a very
welcome development, and we in sub-Saharan Africa will remain grateful to
this new body. However, in cajoling developing nations to introduce new or
under-used vaccines, GAVI must understand that unless the Alliance takes
into account individual nations' peculiarities, the initiative may do more
harm than good.
As for representation on the Global Health Fund, I hope that
developing countries will get not less than one-third of the seats
because, although they would be mere receipients of aid, their input is
crucial to the success of this laudable initiative.
Competing interests: No competing interests