The WHO must reform for its own health (PERSPECTIVE)

(Video WHO video for World Health Day, April 7, 2012)

By Tikki Pang and Laurie Garrett

The World Health Organization (WHO) is facing an unprecedented crisis that threatens its position as the premier international health agency. To ensure its leading role, it must rethink its internal governance and revamp its financing mechanisms.

The World Health Organization was born in the bifurcated Cold War world in 1948, and every aspect of its charter, mission and organizational structure was molded by diplomatic tensions between NATO and the USSR. However, with the collapse of the Soviet Union and the rise of the new emerging market superpowers, the WHO finds itself trying to straddle a global dynamic for which it was not designed.

Indeed, the WHO now finds itself marginalized in a crowded global health landscape characterized by poor coordination among multiple players. It is no longer the only major actor. At the same time, it faces an internal crisis, with major budget shortfalls and staff layoffs that have resulted in the organization embarking on the most radical reforms in its 64-year history. But the changes do not go far enough. A recent dialogue on WHO reform that we participated in, held by the Council on Foreign Relations in New York in February, identified several key challenges that should be addressed by the agency.

(GRAPH: Flag of the WHO) First and foremost, the WHO should refocus on its original aim of being primarily a 'knowledge broker' that gives advice and information about best practices but stops short of directly implementing programs. It should convene negotiations resulting in internationally binding legal agreements and monitor their implementation. Some of its most successful achievements - such as the Framework Convention on Tobacco Control, the International Health Regulations and the International Classification of Diseases - fall into this category.

The means by which such agreements are reached has changed, and the organization needs to adapt. In 1948, the WHO acted as a knowledge-and-standards broker between states, working almost exclusively with ministries of health and government leaders. In the twenty-first century, however, the WHO's credibility and relevance depend on its ability to exert a normative influence through the Internet, informing the global citizenry about all aspects of health - from relevant treaties to drug safety to disease outbreaks. Currently, the organization's website, is nearly impossible to navigate, akin to a well-stocked library with no catalog system. It needs an overhaul to be useful to the global citizenry.

The WHO not only needs to better communicate and coordinate with its global partners; it also needs to make improvements within, starting with its internal governance. The organization must enhance the relationship between its Geneva headquarters and its powerful regional offices. Guidance from Geneva is sometimes ignored, even contradicted, by the regional directors and their offices. Although the WHO was born with a clear top-down leadership structure, it has morphed over the decades into something closer to a partnership: Geneva 'suggests' policies that its regional partners may accept, ignore or amend. It is often difficult to tell whether the tail is wagging the dog. For example, the Pan American Health Organization, which is one of the regional offices of the WHO, may choose to design and implement a Chagas disease eradication strategy having sought little or no input from Geneva. To avoid tensions, the organization should more clearly apportion 'core' versus 'support' roles played by the various parties.

(PHOTO: Dr. Margaret Chan is the Director-General of WHO, appointed by the World Health Assembly on 9 November 2006/WHO)The internal changes must also involve improved finances. In 1990, the agency was by far the largest player on the global health field, with an annual budget of nearly $1.2 billion; the next biggest budget at the time was that of US government global health programs, which totaled $850 million. By 2010, the WHO's budget, after years of increases, fell back to that 1990 level, making it the fourth largest spender in the global health landscape, behind the now-mammoth $7.5 billion US program, the $3 billion Global Fund to Fight AIDS, Tuberculosis and Malaria and the $2.2 billion collective pile of smaller nongovernmental organizations. This year, the WHO seems to be falling further behind in the hierarchy, trailing the GAVI Alliance and the Bill & Melinda Gates Foundation.

Until recently, the WHO garnered more than 80% of its budget in the form of voluntary donations, largely given by the wealthiest countries for earmarked programs. The agency's core support is derived from proportional levies on member nations, which have remained unchanged for years despite the rising costs of WHO operations. Moreover, the WHO's revenues are received in US dollars, but its Geneva operational and payroll costs must be met in Swiss francs. Because the WHO has not practiced currency hedging, a 32% increase in the value of the franc against the dollar, as occurred in 2011, cannot be accommodated without severe institutional fiscal pain.

In addition to practicing currency hedging, the WHO must identify a range of financing innovations with a goal of increasing institutional resilience. Such financing mechanisms may include, for example, the establishment of an endowment fund, a multiyear financing framework, or the use of a Robin Hood tax, which reaps financing from miniscule taxation of very large currency transactions. Both of these options were highlighted by a 5 April report from a consultative expert working group convened by the WHO.

And, like any multibillion-dollar company, the WHO should have an effective 'marketing' strategy built around rigorous, external evaluations that demonstrate the value of its activities.

The world needs an aggressive and scientifically solid health leader. Governance and the setting of normative standards cannot be accomplished with a slew of loosely connected health initiatives, nongovernmental organizations and bilateral programs. The only entity with a charter, a legislative body and a mandate to fill that role is the WHO, and it must do so decisively.

--- This commentary originally appeared in NATURE.  Tikki Pang is a visiting professor at the National University of Singapore and former director of Research Policy & Cooperation at the World Health Organization in Geneva, Switzerland.  Laurie Garrett is a senior fellow for global health at the Council on Foreign Relations in New York, NY, USA.

On World No Tobacco Day The Ubiquitous Hookah Comes Under Attack (NEWS BRIEF)

A Hookah lounge in the UK(HN, May 31, 2011) -- On World No Tobacco Day the World Health Organization (WHO) once again warns smokers and others of the dangers of smoking. While the dangerous habit is declining it is still the leading preventable cause of death.

This year, WHO says more than 5 million people will die from a tobacco-related heart attack, stroke, cancer, lung ailment or other disease. That does not include the more than 600,000 people – more than a quarter of them children – who will die from exposure to second-hand smoke.

Now with use of the so-called Hookah, or water-pipe (also known as "shisha" and "narghile"), proliferating globally - including in the United States - WHO is taking a tough stand on the exotic habit - saying it is no less safe than ordinary smoking.

That the practice is seen to be safe is an "unsubstantiated belief" and reinforced by misleading marketing, WHO says. In an advisory note, the Geneva-based organization says that the label of a popular water-pipe tobacco brand sold in South-West Asia and North America claims 0.5% nicotine and zero percent tar.

The New York Times reports today that many US campuses, where Hookah smoking is becoming extremely popular among college students, are banning the practice all together because of health concerns. Several municipalities are following suit. The habit is also popular among young people in Brazil and European countries.

Hookah pipes and accessories are now easily available online and there is no lack of on-line forums celebrating the practice, such as the Hookah Forum.

Hookah smoking is especially popular in US cities with large numbers of immigrants from the Middle East. The aromatic smoke, filtered through a water bowl, seems to lull users into thinking that the health effects are minimal.

But WHO says that, because the inhaled air passes over not just the tobacco but heated charcoal as well, that users are inhaling very harmful charcoal combustion products.

"Contrary to ancient lore and popular belief, the smoke that emerges from a water-pipe contains numerous toxicants known to cause lung cancer, heart disease and other disease," WHO says. It adds that because the tobacco products contain nicotine it can cause addiction.

Alarmingly, WHO calculates that because a typical Hookah session can last up to more than one hour and include as many as 200 puffs, the water-pipe smoker may therefore inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 cigarettes or more."

WHO says that in South-West Asia and North Africa, it is not uncommon for children to smoke with their parents.

Globally, the highest rates of water-pipe smoking are in North Africa, the Eastern Mediterranean region and South-East Asia, WHO says. Most street cafes in Cairo offer water-pipes, alongside cups of strong coffee, and the practice often replaces alcohol in bars and cafes during the holy month of Ramadan in such cities as Amman, Jordan.

The annual death toll from the global epidemic of tobacco use could rise to 8 million by 2030. Having killed 100 million people during the 20th century, tobacco use could kill 1 billion during the 21st century, WHO said.

- HUMNEWS staff

Number of Young Women Smokers in Developing Countries Skyrockets

(HN, June 4, 2010) Young women in developing countries are being targeted by "seductive" advertising from the large tobacco companies and all governments must take immediate action to protect them from harmful messages, says the World Health Organization (WHO).

 WHO says female business owners are prime targets for seductive offers from tobacco companies, such as branded umbrellas or kiosks

The world health body says that if current trends continue, women could soon be on par with men in terms of rates of death due to smoking, creating what one expert called "a very perverse equality."

"The tobacco industry is spending heavily on seductive advertisements that target women - especially in low and middle income countries. The advertisements try to dupe women into believing that tobacco use is associated with beauty and liberation," Dr. Douglas Bettcher, Director of the WHO Tobacco Free Initiative, told a recent press briefing in Geneva. "In effect they have had to offshore their marketing strategies, look for greener pastures."

Of the world's more than one-billion smokers, only about 200 million are women - but WHO warns those numbers could change rapidly.

Experts believe the tobacco industry has made the shift towards women and young adults in order to compensate for the drop off in tobacco use from smokers who have died from cancer, emphysema, heart attacks, stroke, asthma, tuberculosis and other tobacco-related diseases. One WHO expert accused the major tobacco companies of using "predatory marketing strategies" to lure women in developing countries into taking up the smoking habit, adding that state-owned tobacco companies tend to be less aggressive than the multinationals.

Said Bettcher: "They need to always be refreshing these pools and that's why they are looking to low and middle income countries over the last decade - looking at new populations such as young women to light up and support their profit motives."

Among the venues used to lure women and young girls to tobacco are women's magazines and the fashion industry, WHO says. "The industry has studied what makes women 'tick' in the developed and developing countries," said the WHO's Peju Olukoya, adding that they use sporting and music events that draw many young people. In some countries, free cell phones and text messaging campaigns are used heavily to promote cigarettes.

In Egypt, one WHO expert said, tobacco companies are trying to lure more women by producing cigarette packages to resemble perfume boxes. In Nigeria, cigarette companies build stalls with branded umbrellas and even fund school supplies. "As a result of this, the acceptability for the use of cigarettes by women is gradually increasing., In the past cigarettes have always been associated with the red light district in town," said Olukoya, a native of Nigeria.

She added that Big Tobacco sends confusing messages in many developing countries - by promoting slimness in cultures where this is not necessarily valued and by putting forward smoking as liberating. As for messaging to young men: "It's all about the macho..a big man smokes a big cigarette."

Bettcher says the industry's marketing strategy is having its desired impact. In half of the 151 countries surveyed by WHO, about as many girls smoke as boys. "In some of the countries, in fact, even more girls smoke than boys." Countries where there are more girl smokers than boy smokers include: Uruguay, Mexico, Cook Islands, Croatia, Argentina, Senegal, Chile, Colombia and Bulgaria.

Said Bettcher of the rise of female smokers: "This is a serious red flag. It could mean that we are on the cusp of a much worse global tobacco epidemic amongst women. Girls and boys who smoke are likely to remain smokers as adults."

Bettcher said that one can expect "an explosion" in adult women's tobacco use rates in the coming years. "We simply cannot allow this trend to continue. All governments must take action to protect women from tobacco advertising and promotional sponsorship.

"We must empower women to protect themselves and their families from the harms of tobacco use."

Bettcher added that women need to be protected from second hand smoke, especially in countries where women feel powerless. Smoke-free areas in restaurants and help to cope with addiction are among the steps recommended.

Of the 430,00 adults who die from second-hand smoke each year, well over half - 64 percent - are women. And of the more than 5 million people who die from tobacco use each year, about 1.5 million are women. "Most of these tobacco-related deaths occur in low and middle income countries, which can least afford such dreadful losses," said Bettcher.

By 2030, there could be as many as 8 million people who die from tobacco, of which 2.5 million will be amongst women.

In the Asia-Pacific region, more than 8 per cent of girls between 13 and 15, or around 4.7 million girls, are using tobacco products, said WHO.

Betcher called the new trends - where women became as likely as men to die of smoke-related reasons - a "very perverse equality."

WHO chose as the theme for the recent World No Tobacco Day 2010 as "Gender and Tobacco With an Emphasis on Marketing to Women."  WHO recommends that tobacco advertising and sponsorship should be completely banned. In the US alone, 11 percent of advertising and promotional expenditures in 1996 came from the tobacco industry; in 2005 $13.11 billion was spent on tobacco advertising and promotions.

In 2006, only 17 countries in the world had comprehensive bans against tobacco advertising, and Bettcher said some wealthy countries "dont do very well" in terms of enforcing bans. In response to bans, tobacco companies have become more sophisticated, turning to such tactics as product placement in movies and sponsorships of popular events.

That tobacco companies are tailoring their marketing strategies increasingly towards women in developing countries is nothing new. In 2003, the American Cancer Society flagged the issue as very serious. "The tobacco industry has intensified its marketing strategies -- especially those targeting women -- in developing countries,” said Michael J. Thun, vice president of epidemiology and surveillance research for the American Cancer Society. “International measures such as the WHO Framework Convention on Tobacco Control are essential to help countries protect themselves.”

Staff, files