The Global War for Public Health
So this is the way the world ends, not with a bang but … a cough. Shocked by anthrax attacks and widespread talk of other types of bioterrorism, today's cataclysmists can perhaps be forgiven their fears that Western civilization faces a fatal threat. But for Gro Harlem Brundtland, the director-general of the World Health Organization, it's just another day at the office. As leader of the global fight to protect public health, Brundtland already contends with current plagues such as AIDS, malaria, and tuberculosis -- diseases whose daily death toll is measured not in headlined ones or twos, but in anonymous tens of thousands. Her foes in that struggle are not terrorists, but tight-fisted politicians, recalcitrant bureaucrats, and hard-nosed corporate executives. Luckily, Brundtland's experience and tenacity as three-time prime minister of Norway and head of the World Commission on Environment and Development (known as the Brundtland Commission) have made her not just one of the world's most seasoned female politicians, but what one observer called "a warrior for public health." Here, in an October 18, 2001, conversation with FP Editor Moisés Naím in New York City, she talks about tomorrow's greatest health threats, the best and worst of global medical care, her fight against Big Tobacco and Big Drugs, and the vital role her underfunded, increasingly politicized institution plays in the unending war against disease and poverty.
Foreign Policy: Dr. Brundtland, in 1978, the World Health Organization (WHO) issued a declaration on primary healthcare saying that by the year 2000, "A genuine policy of independence, peace, détente and disarmament could and should release additional resources that could well be devoted to peaceful aims and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share." More than 20 years after that declaration, and even after the end of the Cold War, military spending may be down, but spending on public health has not seen a corresponding increase. And in some instances, maladies and epidemics that we thought had been eradicated have returned. What happened?
Gro Brundtland: The reality is that since that time, there have been positive trends in some areas of public health. It’s not as if everything has headed downhill since 1978. But the goal of attaining a new level of commitment — you didn’t quote it, but the goal of "health for all" was also set out in that same document — remains elusive. Compared with the enthusiasm of the people who met at that time, many things have gone wrong. For example, Africa has fallen behind in real terms, and not just in relation to rich countries.
FP: Another example: the WHO issued a report in 1999 saying that infectious diseases cause 48 percent of deaths worldwide of people under the age of 45. But many of these diseases are curable and preventable. The challenge is to induce donors in rich countries to give more and to persuade recipient countries to spend the money they get more wisely. How do you accomplish those goals?
GB: There are several other important aspects to the problem. First, many of the world’s poorest countries have become caught up in conflict and crisis. Africa is a good example of that. Moreover, the dramatic collapse of the Soviet bloc also had a negative impact in some ways on global public health. The centralized socialist or communist-based systems had some positive attributes in terms of providing all their citizens with health and education. Today, the economies of the Eastern bloc and the former Soviet republics are not flourishing, and their old public health systems have been undermined.
FP: What do you think explains the troubled history of the WHO? You would expect that an organization like the WHO would have more consequence, more presence, and more influence. That has not been the case. What explains the weaknesses and failures of the WHO in failing to reach the ambitious goals it set for itself in 1978?
GB: If you look at nation-building organizations in health, education, or even trade — like the World Trade Organization (WTO) and GATT before it, or the United Nations Education, Scientific and Cultural Organization (UNESCO) — the organizations of the international system are designed to rally support for common causes and to help the poorest countries deal with those key issues. Their task is to serve each member state, whether rich or poor, and provide it with global common goods, such as good professional advice and the sharing and spreading of knowledge. In my view, their job is not to take over the health sector or the efforts that have to do with people’s health in the member states. When you see how different the health systems are around the world, you see how much the health sector reflects the political and economic system of each country. We can set standards in areas where there is a reasonable agreement about facts and technical medical content. But on the more political front about how to finance healthcare, or what part of the gross domestic product (GDP) should go to health — all of these issues are deeply political and they certainly are not decided, in any way, by an international institution with just under 4,000 people.
FP: So essentially, the WHO is more or less congenitally incapable of playing a decisively influential role.
GB: You have to look upon the WHO and other basic organizations of the United Nations family as the core institutions to make healthy member states move forward in areas of common interest.
FP: So what do you think is the WHO’s most important role?
GB: To set standards and norms.
FP: For example?
GB: Well, let’s start with the essential drugs list, which gives a global universal standard with regard to the medications needed to treat key diseases worldwide. People who are designing or maintaining health systems can turn to a list of medications — over 300 or so now — that they know are essential for any functioning health system, because we know what diseases populations have. We use the knowledge base of the whole world to develop that list, which helps countries as they make their own conclusions. That’s one example of a guideline or a standard-setting role that is very helpful to countries and to civil society.
Nongovernmental organizations (NGOs) use it as well, not only governments. Another example is the standards we are developing through our Framework Convention on Tobacco Control, which we started negotiating in October 2000.
FP: Why not do something like that for alcohol?
GB: We are, but we haven’t chosen to come up with the idea of a negotiated framework convention as we have for tobacco, because tobacco is the only product sold on the market that kills half its users when it is used as intended. So tobacco is a very exceptional thing. It kills and the damage is indisputable. And you cannot control it without an international convention because of smuggling and because of advertising coming into people’s homes via satellites. You cannot regulate it in just one country.
FP: In 1998 you said you were fighting to have science taken seriously by politics.
GB: Yes. One of my goals has been to create centers of excellence for spreading the knowledge that helps politicians and societies make the right decisions.
FP: In that case, how do you feel about President Thabo Mbeki of South Africa questioning the link between HIV and AIDS?
GB: I disagree with him and I’ve told him. But what Mbeki says, of course, is also true. Poverty is an important aspect of the whole problem. So we can agree on that, although I stress the central role of the virus. Without it, we wouldn’t have aids.
FP: Yet if the current World Bank’s budget for public health considerably outstrips your own, which is also decreasing, are you succeeding in having politicians take science seriously?
GB: I believe we are, yes. Our budget is part of the U.N. system’s budget. So our budget is directly affected by the decision of the United Nations’ major players to freeze the budget of the United Nations, including the specialized agencies. I have been arguing strongly against this mind-set, because over time, our resources are shrinking in real terms. We have had a great increase since 1998 in extra-budgetary voluntary funding, which means that we have a considerably higher resource base now than we had three years ago. But it is not in the regular budget. It is in our extra-budgetary funding in key areas like malaria, HIV/AIDS, and so on.
FP: What country is an ideal member of the WHO? Which country do you admire for its commitment to support global public health?
GB: Although the United States has been a real stopper with regard to the regular budget, it is also a big contributor of extra-budgetary funding to the WHO. Then you have those who argue strongly for a bigger regular budget, like the Nordic countries, like the Netherlands. The United Kingdom also is a big extra-budgetary contributor, as well as Japan.
ABORTIONS, YES. CIGARETTES, NO.
FP: Donna Shalala, the former U.S. secretary of health and human services, called you a warrior for public health. What battles do you feel you have won, and which ones have you lost?
GB: I think Shalala was sitting in the World Health Assembly, the WHO’s governing body, when I gave my first speech as I was being elected. And I said, I am a doctor. Tobacco is a killer. Tobacco should not be subsidized, glamorized, or advertised. She understood I was a warrior when she heard those words. Because you need a consistent effort over years to really take on the tobacco threat. It’s a tough issue because you create strong opposition.
FP: But tobacco is not your only struggle. The WHO is also playing a strong role in the fight over reproductive healthcare and reproductive rights. The WHO and you are certainly pro-choice.
FP: And you know that stance touches very sensitive nerves in some countries, especially in the United States. What’s your experience in trying to promote a pro-choice agenda? Especially when one of the first decisions of the Bush administration was to reverse the Clinton administration’s population control policies by denying federal funds to family planning organizations that provide abortion counseling or services overseas?
GB: The language from the 1994 International Conference on Population and Development in Cairo is what carries us forward, because nobody really denies women the right to reproductive health. Because women are in a vulnerable time in their lives and need attention when they bear children, family planning is generally accepted. The contentious issue is, first of all, abortion. And the language of Cairo makes it clear that when abortion is legal, women should have access to it. But that language also has this caveat of legality.
FP: But you think abortion should be legal.
GB: What I said at Cairo, which made world news at that time, was that we should at least decriminalize abortion. What I meant by that was avoiding prosecution of women who were in an inherently vulnerable situation — who had had abortions, whether legal or illegal, and who were then patients bleeding or under threat of dying. At the time, that was kind of revolutionary to say, but now it is really accepted.
FP: But the debate over reproductive health is not only over abortion. The sister organization of the who, the United Nations Population Fund, reported in 2000 that 350 million couples do not have access to safe and effective contraceptive methods, and millions of couples lack even the most basic information about birth control. That report states that about 175 million unwanted pregnancies occur each year, about 20 percent of those end up in unsafe abortions, and more than half a million women per year die as a consequence. The report highlights the lack of funding for providing contraceptives to countries and people that need it, noting that contributions will continue to decline in the forseeable future.
GB: We have been arguing strongly over these last years that there is a need to scale up the efforts to fight the diseases of poverty, and in this case, childhood and maternal illnesses are strongly linked to the aspect that you are talking about here. A year and a half after I entered the WHO, I launched the Commission on Macroeconomics and Health, now led by Harvard economist Jeffrey Sachs and including other well-known economists and health specialists. They have analyzed the links between illness and health and economic productivity and economic development and will come out in December with a major report calling for not $1 billion or even $2 billion in funding, but more like $20 billion in added international resources for development in the health sector. It sounds like a lot of money, but it is far below what has already been promised, namely 0.7 percent of a country’s GDP for official development assistance. In the health sector you really see the consequences of the lack of funding in terms of both illness and death, but also in economic activity. People who are ill are not going to be productive, and they are not going to be well educated. If you are sick, you are not going to be earning or learning.
FP: What is your main frustration, other than money?
GB: Well, sometimes lack of cooperation in pursuing common goals.
FP: Lack of cooperation from whom?
GB: It can be between agencies. It can be between different donors. It can be between advocacy groups who are focusing on their own agendas.
FP: Between 1981 and 1996, you served three different times as the prime minister of Norway. You ran a country, and now you run a multilateral organization. When you were prime minister, surely you were used to the difficulties and frustrations of building coalitions and working with different interest groups. That’s not a strange world for you; you have experience in that. What has been the biggest management surprise since you took over the WHO?
GB: At a national level, it is easier to have accountability over time, for instance, between a government and a parliament, and the parties who then compose the representatives in a parliament. Over time, you have a greater ability to ask for consistency, because you have a kind of transparency — you have decision making where the parliament is involved, and then you move on. If you make a health sector reform and it has a majority, then people don’t come one or two years later and question the whole issue without having a very good argument. In the international community, issues are never closed. The decision-making structure is different. It’s based on resolutions —
FP: So you think you’ve reached an agreement, and one year later, you find yourself having to renegotiate.
GB: In fact, you also have a lot of consistency in groups of countries and countries’ approaches to the same kinds of issues over time, but you always have to try to create a consensus. In a national parliamentary system, you can vote, and the majority decides. Building consensus is a bigger challenge, in many ways.
IMMUNE TO REFORM
FP: There are many competing visions about how a nation should organize a healthcare system. The United States had a huge debate about the U.S. health system early in the Clinton administration and did not succeed in reforming it. Most poor countries are struggling to find ways to fund and finance public health. The Europeans have one system; the Canadians have another system. In all of them, the big issues have to do with the balance between the private and the public sector. What do you think are the most important characteristics or elements of an ideal public health system?
GB: Well, it has to be universally accessible and equitable, in the sense that the poor are not excluded from the system in an indirect way because they cannot pay any fees.
FP: Should everybody have access to all health services? I’m referring to the issue of rationing expensive procedures and grappling with the high costs of high technology.
GB: Before we even start talking about rationing, we have to talk about accessibility to all the regular, effective, normal interventions and preventions — FP: Which constitute the bulk of the demand for healthcare.
GB: Yes, because if you look at the world, maybe 30 percent of the world population has absolutely no access.
FP: Who should own the hospitals in this ideal system?
GB: It is not essential whether the ownership is private or public. The essential thing is the stewardship of the system, the financing — that it is fairly financed, which means the poor are, in some way, protected as they get sick. So you can have a prepayment system where middle- and high-income people pay relatively more than those who are poor, or the poorest pay nothing. But you have to have national governmental stewardship over the system.
FP: From this perspective, how would you rank the American system?
GB: The American system does not give access to everybody, which is a weakness. People in the United States can really suffer economic loss and family tragedy when a person gets sick. The use of resources is uneven, financing is unfair, and access is based too much on the ability to pay. People who can pay get high-level attention and access to the most advanced technologies, and then you have a big tail of just under 40 million people who don’t have access.
FP: Which country has a system that you admire?
GB: WHO made the first attempt to really assess performance of health systems in 2000 in our World Health Report. The countries that ranked high on that list were countries like France, as well as some of the countries in the Gulf region, where they have developed a public health system with universal access.
FP: That report was criticized because it ranked San Marino, with a population of 27,000, as having the world’s third best healthcare system and the U.S. health system as the 37th best.
GB: Yes, because of the inequity. We defined our criteria, namely, fairness in financing, equity with regard to access and, of course, the level of health. The U.S. ranks relatively high on the level of health, but not in the distribution of health.
FP: And which poor country has a healthcare system that you admire?
GB: One poor country that does relatively well with regard to health indicators is Sri Lanka. If you compare health indicators in Sri Lanka and India, you’ll see a big difference, although the countries are at a similar economic level.
FP: What are the Sri Lankans doing right?
GB: They have a primary healthcare system — that the WHO defines as essential healthcare based on practical, scientific, and socially acceptable methods and technology. And they have a system that provides wide access to the people. In India, hundreds of millions of people have no access.
FP: What are the main obstacles to reforming a healthcare system? Assume I am a recently elected head of state who calls you and says, Dr. Brundtland, my main priority is to reform my healthcare system, to move it in the direction of your standards. Who are my enemies? Who are the political actors that are going to stop me or derail my efforts? What advice would you give me?
GB: The biggest challenge facing a low- or middle-income country that wants to move to a better health system that reaches all is how to raise money and broaden the tax base. The ones who will resist your idea are those who have to pay those taxes, people who have higher than average incomes or who are rich, and they couldn’t care less about paying more taxes.
FP: Now, assume that you have the money. What happens next?
GB: Let’s take the example of my country, Norway. We have tried to develop a more rational approach to the health system at a high level in a country that is rich. But we tried to do so within the framework of 19 counties, in which each has a certain amount of money for high schools and hospitals. So we got systems that were not always rational or economically effective. Although the idea behind this system was that it was closer to the people, in the end, it meant competition between hospitals trying to keep their own patients within their county. So, in 1997, we reestablished the state as a bigger player in our health system, including the hospitals. This reform has met a lot of opposition, both from public workers in the hospital systems of each county and by the politicians in each county, because they didn’t want to give away power over hospitals and the health sector. We had two important obstacles there: the politicians at the local level and the public workers at the local level.
FP: What about in the private sector? How should a healthcare reformer think about big, private sector companies?
GB: When you change, reform, or even create a financing system, it will influence the people who produce and sell medical technologies and pharmaceuticals — which is another part of the game with regard to buying medicines. You have to think about who pays what kinds of prices, who is responsible for the decisions, and what leeway physicians have in deciding on medications.
FP: And if this hypothetical healthcare reformer asks you, Dr. Brundtland, what do you advise me about price controls? Under what conditions should I just have a unit of my government fix or decide the prices of medicines, hospital supplies —
GB: That cannot be done in practice, so I wouldn’t advise that.
FP: Then how do you keep a lid on prices?
GB: You can have market strength by buying in large volumes, that kind of thing. But you really cannot succeed, I think, with a price control system in a strict sense.
FP: How do you reward investment and risk-taking by companies that produce drugs and do scientific research in a way that takes into account the costs of research and development but also enables people who desperately need these products to purchase them at affordable prices? AODS is a good example. In 2000, you were successful in reaching an agreement where companies that produced the medicines needed to treat HIV/AIDS brought down the yearly treatment from $10,000 to $1,000 per person in Africa. Yet most of these African countries have only $5 to $10 per person per year to devote to these treatments. What good does a reduction from $10,000 to $1,000 do if the treatment is still 100 times more expensive than what these countries can afford?
GB: There is no way to deal with this issue except by a combination of getting those prices down as far as possible (including through competition with generic production), getting companies to pay for treating their workers and their families (some companies have started doing this), and getting rich countries to fund a health system that can handle not just aids, but tuberculosis, malaria, and other diseases and conditions. Poor countries can possibly increase their per capita funding from $10 to $20, but they need to get up to $40 or $50 in order to cover their populations at a reasonable level. That funding has to come from outside, at least until these countries’ economies grow to another level.
FP: So that’s an answer that has to do, again, with the design of the public health system in poor countries. But is there any change needed in the current system of intellectual property law? Is there a major flaw in the way the system currently works that you think needs to be revised?
GB: What we have achieved in collaboration with pharmaceutical companies is that they are now willing to get their prices for poor countries down to a no-profit level. In turn, this means the rest of us in the world will pay for investment, research, and everything that you talked about. That is the best way to deal with a patent system, which has to protect intellectual property to inspire future investment in new medicines.
FP: This public-private partnership that you have been promoting has raised various concerns. Consumer advocate Ralph Nader, in an open letter to you in July 2001, said, "Many are concerned that the WHO has permitted a handful of large pharmaceutical companies to exercise undue influence over its policies and programs, and that in particular, the who has been intimidated and deterred from exercising leadership on a wide range of trade related issues and has shrunk from its traditional role in promoting the use of generic drugs in poor countries."
GB: We really worked hard to answer Nader’s letter. But we have not been intimidated. We promote generic competition. And we promote it using the safeguards of the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement.
FP: So your answer is that you still have a leadership role and that the WHO has not abdicated the promotion of the use of generic drugs.
GB: Yes. I want to emphasize that we have never advocated policies in the WHO that were designed to be an alternative to the international trade system. Our 191 member states are the same member states that are — at least 150 of them or so — in the WTO. What we do is take care of the health aspects of trade-related issues and give advice to health ministers and governments about how they can develop a system that will increase availability and access to drugs and how they can promote competition with generic production so they can push prices down for the benefit of their own people. It’s a complex issue, however, because in some cases, there are no generic versions of medications like AZT to fight aids. The only way we can get those medications to those people is by pushing the prices down and helping them fund the purchases.
FP: In 2000, the WHO released an explosive report that charged tobacco companies with engaging in a systematic effort, dating back decades, to undermine and subvert the WHO’s tobacco control efforts. Can you give me a concrete example of such an effort?
GB: They have tried in many ways that are not immediately obvious. Shortly before I arrived at the who, a who unit on cancer research in Lyon, France, was dealing with the issue of passive smoking (secondhand smoke) and looking at the risks involved. As you might imagine, that study was important for the tobacco industry, because if it came out saying that passive smoking is a risk, then it would pose a major challenge to the industry’s argument about freedom of choice — people must be allowed to smoke, and they are only harming themselves if they are harming anyone. So they tried to influence the people doing the research in a variety of direct and indirect ways, using researchers from NGOs (whose links to the tobacco industry were not identified) to question results, and publishing a counterattack on the report before its publication.
FP: Do you feel that tobacco companies still engage in these sorts of tactics?
GB: Because we published the report you’re talking about and because we looked through all possibilities in a systematic way, the tobacco companies are now aware they are being watched and that it’s risky for them. We don’t know what they do, but we are quite certain this led many to be more careful. Our actions might possibly stop them from doing this kind of thing.
FP: The World Health Assembly in May 2000 protested Israel’s excessive use of force against the Palestinians and voiced a "grave concern" about Israel’s settlement policies and stressed its support for the Palestinian right to self determination. Are these appropriate issues for the WHO to be addressing?
GB: The member states decide what they choose to say, and in that case, there were discussions about whether this was right or not.
FP: We know that the U.N. member countries have a right to state their opinions, but you, as an individual, must have an opinion — and you lead this organization — about whether this is the right thing.
GB: What is happening more and more is that political issues cross all of our international institutions. If they are key enough in a number of countries’ minds, they will break a traditional barrier between different parts of the system, and they will be addressed.
FP: If the governance structure of the who would allow the director-general to decide on the agenda of the meetings or to drop issues that the director-general thinks are not within the priorities or even the mandate of the WHO, would you have allowed this type of agenda item?
GB: I would say that we should focus, first of all, on global health issues. You can widen that to poverty, which I have talked about a lot. To reduce poverty, you have to invest in health. A wide interpretation of the health agenda covers development, poverty, population, and the environment — a broad range of issues. However, as you then look at those key issues, you get into political conflicts between different member states, and the member delegations to the who in Geneva are instructed by the same foreign ministries that instruct their counterparts at the United Nations in New York. Is it necessary to repeat debates and resolutions from the United Nations in New York? That’s a question I often ask myself. But the other thing I would say is that U.N. institutions are not independent entities led by people who have personal mandates. We have secretariats to address issues, to analyze issues. I have my right to propose, which is a very important thing, but I cannot start vetoing what member states come to say.
FP: The Taiwanese government has argued that because of Taiwan’s location and the amount of trade conducted across its borders, the potential world health risk of Taiwan’s continued exclusion from the WHO and its infectious diseases information sharing is truly staggering. Do you agree?
GB: They are not really excluded from information sharing. They have access to all of our documents, everything. So the problem, again, is a political one. In this case, those who want a change in Taiwan’s status use health concerns to make their point. But really, if there’s going to be a change with regard to China and Taiwan in the U.N. system, that decision should be made in New York at the United Nations, not in Geneva at the WHO.
FP: You mentioned already that at the U.N. conference in Cairo in 1994, you aroused the ire of some Catholics and Muslims by calling for the decriminalization of abortion. In the fight to promote public health, what are the instances in which organized religion can be an obstacle?
GB: So many societies have a combination of religious beliefs and authoritarian pressure, even legally or in societal terms, that disempowers women or girls. We saw that when we worked on the Cairo and Beijing conferences, the Children’s Summit, and so on. So these attitudes illustrate a tradition where still there is discrimination against women. Often this discrimination is linked to religion, with governments and leaders using religion as an argument to continue discriminating and disempowering women and girls. Girls don’t even have the legal rights to inherit or the rights to education that boys have (as is the case in Nepal, where even though girls can now inherit property at birth they must still return it on marriage). If you look at the Bible or the Koran, you don’t find these negative aspects. But the way religion functions in practice sometimes leads to these kinds of discriminatory approaches. And not just with regard to reproductive health; it is the same with the role of women and girls, and in many cases, in the whole economic and social life of countries.
FP: You and I are talking as the United States faces widespread reports of anthrax attacks and cases. Do you envision that the WHO is going to play a role in the fight against bioterrorism?
GB: Definitely. Three weeks ago, just after the September 11 attacks, we decided to push forward a revision of a 1970 manual discussing the health aspects of biological and chemical weapons. That publication was being revisited and updated, and it was due to be published in December 2001. So we quickly, over two or three days, went through the text as it stood and placed the revised text on the Web, because it was necessary to get this information out.
FP: What would your advice be, not as the head of the WHO but as a former head of state and a politician with a global perspective, if a state or a government is discovered to be behind the production of anthrax for use by international terrorists? What should happen? What policy prescription should the world follow? What would you recommend?
GB: I am the director-general of the WHO and have to deal with it from that perspective. The role of the WHO is to help countries develop the surveillance capacity, contingency planning, and public health system.