Questions over future of global diabetes group as founding members resignBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l995 (Published 05 March 2019) Cite this as: BMJ 2019;364:l995
- Melanie Newman, freelance journalist, London, UK
For almost 70 years, the International Diabetes Federation (IDF) has led global efforts to combat diabetes. But its work has been so seriously undermined by internal conflict and the resignation of four founding members that its supporters are now questioning whether the organisation will survive.
An umbrella organisation of more than 200 diabetes associations from some 160 countries, IDF’s activities have ranged from lobbying the United Nations to initiatives such as Life for a Child, which helps children with diabetes in lower income countries to access treatment. Raising sufficient funds has been a challenge, and the institution has been dogged by accusations of cosiness with the drug industry.1
Now, after conversations with dozens of people from inside and outside the IDF and having seen some of the relevant documents, The BMJ can reveal widespread disquiet about the organisation’s governance under current president, Nam Cho (from Korea), and his predecessor, Shaukat Sadikot (from India). Both men have made or tried to make highly contentious changes to IDF activities, programmes, and staffing since 2016. In the past few years, national diabetes associations from the UK, France, Netherlands, and Denmark have all cut ties with the federation. The German association is monitoring the situation “very closely.”
Mostly recently, the leadership has attempted to remove elected board members—including Cho’s planned successor, Andrew Boulton, professor of medicine at Manchester University—and to take control of Life for a Child away from its longstanding operator and funder, Diabetes New South Wales. Other controversial changes include the federation’s withdrawal from the Non-Communicable Diseases Alliance, a high level lobbying organisation founded by Ann Keeling, a former IDF chief executive.
Critics say some of these actions have been taken without clear authority and with insufficient transparency. A drug company’s large overpayment to the IDF, which came to light in 2016, also became a source of discontent when both Cho and Sadikot made semipublic references to fraud despite no evidence of this having been found.
As a result, several of the IDF’s founding members, including Diabetes UK, have left the federation in the past two years, others are considering doing so, and board members have resigned. Life for a Child’s operators have announced plans to remove the programme from IDF’s auspices.
The departures have been noticed externally: “According to our partners, IDF is losing visibility,” said the federation’s July 2018 board minutes. Time spent managing conflict on so many levels is likely to have distracted the IDF board from its advocacy work.
Stéphane Besançon, director general of French non-governmental organisation Santé Diabète in Mali, attended the high level summit on non-communicable disease in New York during the UN general assembly in September 2018. He tells The BMJ, “IDF was not present enough for advocacy around this meeting.”
He also thinks “IDF does not do enough on the ground in low income countries.” Aside from Life for a Child and Bridges 2, a joint Eli Lilly-IDF project that funds research on diabetes prevention, little else is being done in the field, he says.
Abolition of chief executive role resulted in “continuous interference”
For some IDF critics the first sign of trouble came at the inaugural board meeting of Sadikot’s presidency in January 2016, when the chief executive was dismissed and her position abolished. The result, according to reports from the IDF’s executive office report, was “continuous operational interference.”
“There seems to be a ‘board within the board,’ a group of board members that are being consulted and guided on decision making by the president and president elect,” the same document added. This had created “an organizational culture of suspicion and distrust,” it said, and the disconnect had been noticed by funding partners.
Diabetes associations from the US, UK, Canada, Malta, Denmark, and several Nordic countries wrote to the board arguing for the chief executive role to be retained. But in a postal ballot held in September 2016, most national associations voted in favour of changes to the articles of association that allowed the board to act as chief executive.
Conflicts of interest
Meanwhile concerns were also emerging over the board’s approach to conflicts of interest. The IDF provided board members, staff, and patients with diabetes to speak at industry events. Any speaker fees had historically been paid to the IDF.
The December 2016 IDF executive report states that Novo Nordisk was forced to write into a contract that federation representatives could not claim for honorary fees after at least one IDF speaker claimed a personal honorarium for speaking.
The BMJ asked Cho and Sadikot if they had been personally paid by any drug company since 2016 and, if so, whether conflict of interest declarations had been made to the IDF. No reply has been received.
A different industry related issue also emerged in 2016 that was to substantially widen the divide between Sadikot and the British contingent.
In 2015 AstraZeneca overpaid €1m (£860 000; $1.1m) to the IDF, information about which, for unclear reasons, was not communicated promptly to the board. The matter was investigated by Mazars, the IDF’s auditors, with no evidence of fraud uncovered.
Sadikot later highlighted the AstraZeneca overpayment as evidence of mismanagement during the previous presidency, that of Michael Hirst, which Hirst strongly denied.
In December 2016 three vice presidents resigned, including the two British vice presidents for finance and strategic governance, citing Sadikot’s handling of the overpayment and the removal of the chief executive post.
The third person to resign was a Dutch lay vice president, who in her resignation letter said she was “astonished and shocked” that the president had discussed fraud and financial problems in front of corporate partners at a recent meeting when she as a board member knew nothing about it. The Dutch Diabetes Association disaffiliated from IDF shortly afterwards. The BMJ asked the IDF to respond to this allegation but no response was received.
Fast forward to January 2018, and one of Cho’s first actions as president was to declare the election of the vice president for finance, Graham Spooner, illegitimate because he had postgraduate accountancy qualifications but not an accounting degree.
Cho’s refusal to recognise Spooner’s appointment developed into an increasingly vitriolic dispute with the IDF’s nominating committee, headed by Hirst. The row played out in a semipublic sphere throughout the first half of 2018, with accusations of racism, financial mismanagement, and abuse of expenses flung by players on both sides of the dispute in emails copied to the membership.
“Illegal actions, misuse of funds, and racial discrimination has no place in an international organization,” said one typically cryptic letter from Cho to all IDF member associations.
Six former IDF presidents, including Hirst, and three honorary presidents wrote asking Cho to make available legal advice he said he had taken before firing Spooner, which to date he has not done.
After calling on Cho to “end this divisive and embarrassing behaviour,” Diabetes UK ended its membership in March 2018. “IDF is no longer able to demonstrate the minimum level of robust and transparent governance,” its resignation letter said.
A few months later the French national association told the IDF it would suspend its membership and withdraw completely at the end of the year if its questions about various matters were not answered. These included the Spooner affair, a partnership agreement with the service organisation Lions Club International made without consulting member organisations, a lack of patients on the IDF board, and dependence on pharmaceutical funding.
Cho responded personally. “Today’s world is not like it was in 1950,” he wrote, adding: “You state you will suspend your membership until you receive a response … well, one member association does not control the Board of IDF. The IDF is financially sound, transparent in its actions, and will not tolerate such naive threats.”
Life for a Child debacle
Some people who spoke to The BMJ believe the current IDF leadership is driven by anti-Western sentiment and wants to reduce European and Australian influence. “We are viewed as imperialists,” one complains. Others suggest different cultural attitudes to governance might be at the root of the conflict. Another blames the federation’s structure, under which the board is elected by members, and a “cult of president.” “The presidents can do what they like—the post is an ego trip,” he says.
Whatever the reason, Australian-run Life for a Child became the next flashpoint for dispute. Until 2018, IDF’s role in the project was limited to passing on funds from donors and some staff support. Under Cho IDF decided to take control of it, sidelining long term operator Diabetes New South Wales.
The result was “a breakdown in program governance leading to several supply shortages,” Diabetes NSW wrote to the IDF in September 2018. “Moreover, the IDF has not provided a clear strategic direction or management framework for the program’s future, despite repeated requests.”
Life for a Child would now operate solely under the auspices of the Australian body, the letter added. Drug company Lilly, which provides Life for a Child with insulin and test strips, told TheBMJ it supported the change.
The IDF nevertheless informed members that Life for a Child was moving to Brussels and told Diabetes NSW it would continue to run a programme under that name. In practice this means there will now be two operations fulfilling a similar function. IDF and Diabetes NSW are in dispute over ownership of the name and logo of Life for a Child.
Moves against the president elect
Meanwhile, the withdrawal of Diabetes UK caused an escalation of hostilities against senior British IDF members. In September 2018, the federation’s vice president for governance wrote to president elect Andrew Boulton, board member Angus Forbes, and Niti Pall, chair elect of IDF Europe. All three were asked to resign on grounds that their membership of Diabetes UK represented an unacceptable conflict of interest. Legal advice had been taken, the letter said.
Two months earlier the board had voted down a proposal to remove the three but agreed legal advice should be sought. TheBMJ understands that despite requests the legal opinion has not been shown to board members.
To date, the trio have not resigned, but the move against them prompted the Danish Diabetes Association to cut ties with the IDF. “As soon we are confident about the re-instalment of good governance in IDF Global we will reconsider our membership,” the Danes wrote.
Their resignation had little effect, with Cho reportedly now proposing to amend the IDF’s articles of associations and operating procedures to mandate the removals.
If the three are forced out The BMJ understands more associations are likely to resign, further weakening the IDF’s mandate as a global voice.
German Diabetes Aid says it has “reduced its interactions with and support to IDF to the absolute minimum and is watching the current situation very closely.” Should elected board members lose their current positions it says it would reconsider its position.
Juleen Zierath, president of the European Association for the Study of Diabetes, says: “We are concerned about the governance of IDF. We are keeping a careful watch on the situation and are reconsidering our position frequently.”
A former board member says that if the “unconstitutional and egregious” attempt to oust Boulton is successful “it would drive the final nail into the coffin of corporate support” for the IDF.
Already struggling to cope with a long term decline in external funding and falling attendance at its biannual congress, the IDF can ill afford to lose further support. But it may already be too late.
Cho’s latest move is to launch legal action against Hirst in respect of alleged mismanagement of the IDF during his presidency. Hirst is accused of mismanaging the AstraZeneca overpayment. The IDF is claiming damages of just €1.
Describing the action as “vexatious” Hirst says: “There was no loss, financial or accounting, and the matter was handled perfectly properly by IDF.”
If the IDF loses the case it may have to fund Hirst’s legal expenses as well as its own.
“We should start again,” says one former board member. “Diabetes needs a new advocacy organisation without all these past presidents hanging around.”
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.