Let's Learn from Global Health Failures

The World Health Organization and its member countries are holding their annual meeting, known as the World Health Assembly, in Geneva this week. With hopes dashed for meeting its ambitious AIDS prevention and treatment goals, criticisms of its failed Roll Back Malaria Program, and chronic illnesses such as heart disease, cancer and diabetes threatening even the poorest of countries, the organization's limits are being tested.

The greatest tribute to Lee Jong-wook, the WHO director general who died Monday, would be a new commitment to implementing policies that work.

Even before WHO and the United Nations AIDS agency announced their "3 by 5" initiative to treat three million HIV-infected people with life-saving drugs by the end of 2005, the effort was destined to fail. The centrally planned program was not even approved by member states until six months after the announcement.

Instead of learning from existing AIDS programs in the private sector, engaging with other countries' ongoing treatment programs in India, South Africa, Botswana and Brazil, and setting realistic treatment goals, WHO played to the crowds. It proclaimed that unrealistically large numbers of people would be treated quickly.

Sadly, WHO promised much and delivered little. Of the 1.3 million who have been treated for AIDS since Jan. 1, 2004, more than half were funded directly by the pharmaceutical industry's Accelerated Access Initiative and much of the rest came from European governments and U.S. donations to the Global Fund and through President George W. Bush's initiative. Once these numbers revealed the WHO shortfall, the agency downplayed its previously trumpeted goal. WHO must reach out beyond its normal circles of consultants and government health ministries in order to work with local doctors, clinics, hospitals and businesses in fighting AIDS and other diseases.

WHO allowed advocacy to trump science. Routine HIV tests should be a cornerstone of science-based medicine and a global AIDS program, yet WHO decided they were too expensive.

WHO has focused on patents and alleged high prices of AIDS drugs as primary barriers to treatment in poor countries. It recommended using copies of AIDS drugs produced in the developing world - with unknown safety and efficacy - as the key therapies for its "3 by 5" program. In 2004, the global health agency then had to disqualify 18 of these antiretroviral formulations due to lack of proven bioequivalence.

In reality, drug prices have not been a major barrier to treatment. The majority of patented AIDS drugs are either less expensive or the same price as copied drugs, because drug companies either donate them or provide them at highly subsidized prices to developing countries.

The real barriers to AIDS treatment receive little attention from WHO. Substandard and counterfeit medicines may be contributing to dangerous drug- resistant strains of HIV, yet registration of proven drugs continues to be complicated and lengthy.

Developing countries also place exorbitant taxes and tariffs on many essential medicines. The U.S. Mission to the United Nations in Geneva, citing UN statistics, points out that "almost $33 billion in pharmaceuticals and $23 billion in medical equipment are still traded subject to duty, predominantly by developing countries." Accordingly, the United States, Switzerland and Singapore introduced a proposal to eliminate these tariffs and substantially lower the price of medicines for poor people.

To its credit, WHO did admit publicly that its "3 by 5" strategy had failed. But the failed campaign did not prevent WHO from quickly announcing a new "10 by 10" AIDS treatment program - with the goal of treating 10 million people by 2010. The effort calls for $28 billion a year for treatment starting in 2008, even though there are no modifications to WHO's strategy. Should the G-8 countries really be expected to continue footing the bill for proven failure?

Sound medical and public health policies, not publicity and exaggerated numbers, should be WHO's priority. Governments, nongovernmental organizations, industry leaders and global bodies should check their ideological guns at the door and work in good faith to break down the real obstacles to AIDS treatment. Developing countries need to provide the leadership for improved health care infrastructure as well.

It is time for WHO to rethink its strategies and modus operandi. It must reach out to new health care players in developing countries, reorient itself to science- based medicine, and reclaim a leadership role to meet the looming public health challenges. The world's global health authority must stop chasing numbers in order to achieve the desired bureaucratic outcome and instead focus on testing and evaluation, responsible treatment, and monitoring of AIDS patients.

Health professionals and policy makers around the world will be watching the World Health Assembly for lessons learned from failed campaigns, and hoping that member states demand accountability. WHO should be judged by its performance, not by its rhetoric. Good intentions are not good enough.

 This article appeared in the International Herald Tribune on May 23, 2006.