On the role of WHO, IHR (2005) & Reveres' posts

[JJackson]

Reveres:

Thank you for the series of WHO posts, they were excellent.

I have posted previously on the role of the WHO and have held judgment while you wrote these articles to allow you to make your case and see if my position would shift.

I remain substantially where I started, namely this system does not and will not work and the fault lies mainly with the nation states and to a lesser extent with the WHO.
You said that the IHR (2005) was significantly less Westphalian than its predecessor but it still leaves the WHO impotent. I can find no meaningful role for any non state body (except other UN agencies & intergovernmental bodies both of which operate under state defined mandates).

The onus is squarely on the effected state to report problems within its boarders. If it fails to do so, and the WHO suspects a problem, they can not investigate they are only empowered to inform the state of their information and rely on them to confirm or deny. As far as informing anyone else of a problem the WHO can tell other states (in confidence) if they are convinced it is going to spread internationally. For them to speak to anyone else it must already be in the public domain.

For the system to work the WHO needs teeth. It must be able to enter a sovereign state without invitation to perform its own investigation and release its findings to whomsoever it thinks needs them. It may not need to exercise this right but if states know that power is there, in the final resort, it will ensure compliance. This total dependence on the whim of a state for data or access also hobbles the WHO’s ability to make bold truthful statements as unwelcome pronouncements may cause the withdrawal of cooperation.

As with all law it is fairly meaningless with out precedent. IHR (2005) gives nearly all powers to the Director General of the WHO, committees advise but the DG acts on the WHO’s behalf. A strong DG, unafraid of the reaction of member states, could interpret the release of information to the public clause liberally and provide a stream of data on the WHO’s site including clinical data, treatment regimes & outcomes, dates, cluster relationships etc. The DG could use his/her authority to publicly call for sequence release - or negotiate it behind closed doors - but none of this will happen while our governments leaves the DG begging for scraps.

I am a firm believer in the ‘if it didn’t exist we would have to invent it’ school of thought with regard to the UN and WHO. Unless states are willing to accept that there are occasions when they have to give up a small portion of their sovereignty in the interest of humanity we are all in deep guano.

P.S.
Here is the link to the full IHR (2005) text. http://www.who.int/gb/ebwha/pdf_file.../A58_55-en.pdf
(Articles 6 to 11 & 56 are most relevant)

Edit:
The original link here was broken as at the time of writing the IHR(2005) had recently been ratified. Eight years later and and we are on the second edition (to which the link will take you). As I have not yet read it for changes I can not tell if they have any bearing on the above.

In the event of a dispute on the interpretation of the IHR article 56 calls for states to negotiate and failing a resolution invoke the Permanent Court of Arbitration Optional Rules for Arbitrating Disputes between states. This is not a suitable instrument as the respondent can hold up proceedings for months on panel selection alone as was eloquently demonstrated by Dave Sencers anecdote in another thread.

P.P.S
I will post Dave Sencer's EffectMeasure posts in the experts forum as they are a wonderful example of theory meeting practice. (link)
This link is to a post I wrote covering the application of the flow chart in Annex 2.
My final link is to the first of the series of post by the reveres which prompted this comment.

[JJackson]

Sledge Hammers, nuts and silver linings.

In the series of essays the reveres wrote to which the first post in this thread was, at least in part, a reply they dated the structural weakness? of the UN and WHO back to the treaty of Westphalia in 1648. This was a codifying of international relations reached at the end of the Thirty Years War (1618 ? 1648). This was an appalling pan-european conflict with horrendous mortality (~30%) and no clear victor.

I would like to take you back even further to 1066 the time of the Norman Conquest. The Normans invaded England and as conquers imposed a new system of governance. To calculate the tax they could levy they performed a detailed census of people, property & livestock which was compiled into the Domesday Book and instituted a feudal system of governance. Under feudalism the Norman King owned everything, he appointed Barons with grants of land ? and everything on that land ? and the peasants were a captive workforce indentured to the Baron and through him to the King. This system continued without major change until the Black Death (1347 ? 1351). This pandemic (they were a little short of epidemiologists at the time but possibly caused by Bubonic plague) killed about 30% of the population and left the land owners with a shortage of peasants. Up until this point peasants were chattel and not free to leave their master?s land, it was not in the interests of other landowners to poach workers as the precedent could work both ways. The labour shortage caused a shift from a feudal and principally barter based economy to a more mobile cash based system with property ownership descending further down the social scale.

The aim of all this historical rambling is to show that events with global impact, principally wars and pandemics, have profound influences on social structures. The changes induced by the 1918 pandemic are difficult to detect as they have been subsumed into those of WW1 but the global impact of the combined event are legion.

Sledge hammers, nuts & silver linings: all of the above is a preamble to the consideration of the impact on society of another major event. Major wars tend to be between nation states and leave an even greater feeling of ?us & them?. The aftermath is likely to cause polarisation along state or block lines with some mediation mechanism - be it the treaty of Westphalia, The League of Nations or the UN. But what of conflicts where ?us? is humanity as a whole and ?they? are aliens? In what direction might that impact propel us? Could it lead to a restructuring of our world view and humanities role in it? Might it make us realise that we can not see the wood for the trees and that it is in ?our? best interest to research and develop vax plants for all, accept limitations of sovereignty for the benefit of all, view disease prevention, global warming, over fishing, water resources et al from a global humanitarian perspective rather than some arbitrary parochial view? Could a pandemic crack this nut and have a silver lining ? albeit at a horrific cost.

JJ

[JJackson]

Re: On the role of WHO, IHR (2005) & reveres posts

Indonesia, WHO, Samples & Vaccine.

I have posted this here as it seems to be of a kind with the above posts; in that it is another manifestation of a structural malaise in our current global organisation.

Indonesia were on a hiding to nothing in their attempt to redress a perceived imbalance between the haves and have nots. The problem is not that their grievance is without merit it is just that there is no structural mechanism to address it. Historically they ? along with many other sovereign states -- have provided influenza samples to the WHO, for the general good, on the understanding that they are to be used in updating the two annual flu vaccine formulations, one each for the Northern and Southern hemispheres. Flu vaccine profits have not been one of the items to make Big Pharma executives drool and while seasonal flu is a serious enough problem in its own right the spectre of an H5N1 pandemic is a threat of a quite different order. Indonesia is a country of particularly rich biodiversity and has written into their laws protection for the state against commercial exploitation of what it sees as a natural resource. This is a states reaction to the absurd and obscene trend toward the patenting and copyrighting of all manner of natures ingenious solutions to natural problems which , IMO, have no business being exclusively owned by any individual, corporation or country.

Back to the problem raised by Indonesia. They have played ball and supplied samples and sequences but don?t see any great benefit from doing so, if they then see a company use their freely given sample to make a product ? for profit ? which is then priced at a point which precludes their benefiting form it. The structural problem is that vaccine production is a commercial operation with no altruistic component, it is undertaken by a company only if they think they can make a better return on capital than by investing in some other product, and when you are big pharma that is a significant return. The WHO sounds important but is in a reality not much more than a coordinating body (see the first post in this tread for an explanation of its limitations) it has an annual budget of about $1.5 billion to cover everything health related globally. This may seem like a fair sized budget but when you consider the scope of their mandate it means they have little to spend on pandemic preparedness, or any other single item. To try and put this figure into perspective it is about 1/6th of the CDC?s budget and one year (1989 I think) the advertising budget for Viagra and its competitors was $400 million. Indonesia estimates it needs $300 million p.a. (principally to compensate for slaughtered poultry) while its current total BF budget is ~$50 million p.a. It is obviously tempting for them to try and see if they can get some quid pro quo for their samples but their only option is to try and strike an exclusive deal with one pharmaceutical company; they are the only players with the money and who could potential recoup their investment. If others were to follow this example we could see deals between Botswana for XDR-TB, South Africa for HIV and Thailand for drug resistant malaria. Could your local hospital make money from its strain of MRSA? Followed to its logical conclusion this just exposes the absurdity of the current situation.

I should now provide a viable alternative which would right these wrongs, but I do not have one short of some utopian restructuring of the current world order. Should the danger of HPAI (or some other HP zoonotic) pandemics be viewed as a global problem outside of the rights of any nation or corporation? In my opinion yes.
In the UK we have a heath system which is, in theory, free at the point of need and funded by taxation based on an ability to contribute. A threat to global stability such as an HP AI is a candidate for an experiment in removing the patents, copyrights, research, development & production of vaccine from states and corporations to be managed by the NGO WHO inc. for the benefit of us all. Personally I would add the right to a supply of safe drinking water to this portfolio.

All the above is to be taken as my personal view and not that of Flutrackers. If you agree, disagree or have any comments please post.

[LMonty]

Re: On the role of WHO, IHR (2005) & reveres posts

I should now provide a viable alternative which would right these wrongs, but I do not have one short of some utopian restructuring of the current world order.

Fund the WHO to produce the vaccines themselves. NOT as expensive or difficult as it sounds- could be done for a few dozen million, if it was carried out in a technology rich but inexpensive production zone like India.

[gsgs]

Re: On the role of WHO, IHR (2005) & reveres posts

I had similar discussions about copyrights for software
in the past.
The problem is similar.
My position is, that there should be no copyrights, all software
and sequence data should be free, while some international
organisation rewards researchers for developing new software
or providing new sequences.

Of course, the devil is in the detail here, how much should be rewarded
to which software and how much each member should contribute
to the funding of that international organisation.
But the principle is better than what we have now, IMO.

[JJackson]

Quo Vadimus

Quo Vadimus

In my first post in this thread I argued that the WHO were fighting with one hand tied behind their back because the Nation States, which defined their mandate, would not give them the powers they need to achieve their goals.

In the second I took a rather circuitous route to reach the rather sad conclusion that only a disaster on the scale of a 1918 type pandemic could effect much needed change to the current global Nation State/Multi-national Corporation structure.

In the third I used Indonesia’s attempt to use H5N1 samples as a bargaining chip in negotiating a more equitable distribution of some putative vaccine to highlight weaknesses in the global system but whimped-out when it came to a solution.

In this post I will consider what I think we might be able to do.

I have talked about the current structure without defining it but we must start from our current reality. As I see it the Nation State is the de facto standard unit, this is not a natural or inevitable structure it has come to be the way the globe is divided up by historical accident. I would further argue that it is not a particularly helpful structure especially where it has been arbitrarily applied to land masses, principally by European powers, without adequate recognition of the extant ethnic, tribal or religious boundaries. Apart from the nation states the other main players are the multi-nationals, a plethora of multi-lateral organisations aimed at mediating between the nation states like the UN, World Bank, IMF & GATT and picking up the slack we have the NGOs and foundations like Gates.

In Snowy’s post he argues for an 'Asymetric Return on Investment' as a work-around for the pharmaceutical industry but I am not sure this is the best way to go. Publicly listed corporations, like the pharmaceutical companies, primary responsibility is to their share holders and are very poorly adapted structures for this kind of compromise. The Gates foundation is attacking the problem from a different angle and supplying seed money for the development of drugs to treat diseases whose primary victims are in developing countries with per capita GDP’s too low to cover the investment in profitably bringing the drug to market. What then is the best solution to this Catch 22. The costs are in R&D, clinical trials & certification and the manufacturing costs. The end using countries may be able to pay for the manufacturing cost of the final generic drug but not the whole package. The barriers are the costs getting to the generic drug stage compounded by patents and intellectual copyright problems. My preferred solution would the compulsory purchase (as might happen to my house if the PTB decided to build a motorway through it) of any patents followed by competitive tender for the R&D and clinical trials phase. This would be closer to the Gates model but the funding should not rely on the generosity of individuals but be paid for by international subscription through the UN umbrella with dues paid by the Nation States in line with their existing contributions. The UN is a much maligned body in some quarters but is the logical forum for this kind of endeavour.

As the last post looked at H5N1 vaccine lets take that as an example (although Malaria, AIDs or TB would do just as well). The current situation is that we are using a 1950’s technology of egg based production which is labour intensive, expensive and not scaleable. It also has a long lead time from start of production to finished vaccine, although this is not a big problem for seasonal flu, as the ‘season’ is predictable, it renders this production method fairly useless for pan flu. We are in this situation because there was inadequate financial incentive for big pharma to reinvent the technology and no one else was interested in funding it. The current production capacity is matched to the ‘at risk’ population in the countries rich enough to pay for it (in this case the young, elderly & others with ailments that make seasonal flu life threatening). While season flu causes enormous global financial loses annually, due to worker absence, it is a know quantity and the global market economy allows for it. Pandemic flu occurs a few times a century and the kind of virulent pandemic we fear, and which could cause global chaos, probably only occurs once a century, if that. The first question then becomes ‘is it a sensible use of our resources?’ Given that we are talking about 100 million deaths in a little over a year and severe global recession, even if amortised, I think the answer is probably yes.
What then do we need and how do we get it? First we need a different vaccine production method and realistically we need infrastructure that can be put to other use in the intra-pandemic period. Candidates include cell based production, air lift fermentation of monoclonal antibodies and a restructuring of the animal vaccine production capacity to be switchable for human use. China decided to vaccinate all their poultry against H5N1, they have an estimated 12 billion domestic birds (human flu vaccine capacity ~350 million, human population ~6.6 billion) and as commercial poultry have a short life this means capacity to continually revaccinate this number. We need to be able to vaccinate a large portion of the world’s population – not just in our own countries -- as the type of event we are preparing for would still have catastrophic global economic and social consequences even if we could protect everyone within our boarders.

So to recap the nation states fund the WHO via the UN. The UN/WHO have the power to compulsorily purchase anything they need to get the job done and then contract out the work. The UN then supplies the drugs on a per capita basis. Is this a perfect system? Absolutely not! I can envisage the panic the suggestion would invoke in the Big Pharma lobby, what if it worked and spread to other areas?

[JJackson]

Jeffrey Sachs 2007 Reith Lecture #1

Those of you have been following the above posts may be interested in this link

http://www.bbc.co.uk/radio4/reith2007/?focuswin

It is to the first of this year?s Reith lectures by Jeffrey Sachs, outlining the challenges facing mankind and argues that we must adapt to the new age.

H5N1 gets a mention but I suspect as the series unfolds he too will be arguing for systemic change and that the current structures are not well adapted to cope with shared global challenges.

[gsgs]

Re: On the role of WHO, IHR (2005) & reveres posts

JJackson,

WHO's/UNO's task is to contain an emerging pandemic at its source.
Not to provide/support vaccine stockpiling of the whole world.

So vaccinating of hotspot regions by WHO makes sence when it reduces
the pandemic danger for the world.

The international organisations - you don't mention ASEAN which
is suitable for Indonesia , and you critisize (past?)European powers for
inadequate recognition of ethnic.. borders.

But actually European Union is IMO quite a good example for
international cooperation while keeping the national boundaries.

Health issues like pandemic are being addressed in cooperation
within EU. Also all sorts of other issues, just an example of slowly
increasing cooperation of nations. You'd wish the same could
be done in Asia.

[JJackson]

Re: On the role of WHO, IHR (2005) & reveres posts

gsgs

One of the WHO's current aims is to attempt to contain a nascent pandemic by wrestling the Ro down below 1 with its Tamiflu blanket. Given that very few of those currently infected get Tamiflu within 48 hrs of system onset (current Indonesian average is 5.2 days) and most H5N1 confirmations come late in the disease or post mortem I do not hold up much hope for this approach. Even if it worked once I suspect the circulating sequence would be so close to a true pandemic strain it would just happen again. However my point was the WHO’s mandate should be expanded to include control of global pandemic vaccine production and this should be shifted from egg based production.

“vaccinating of hotspot regions” is not currently an option as the WHO does not have a pandemic vaccine.

I am not sure where ASEAN came into this as it as a regional body and the organisations I listed are global channels for affecting global solution to problems that have no solution at a national level.

The European powers I was referring to are the colonial powers which drew the lines all over Africa, and much of the rest of the world, to create the countries we now find on our maps. Many of the wars on that continent are the result of post independence redefinitions, the same could be said for the Balkan conflicts post Tito. In both cases once the dictator, or colonial power, was gone the people on the ground decided to redraw the map to group themselves with others they viewed as kin. Hence colonial India becomes India, Pakistan & Bangladesh and we wait to see what happens to Kashmir.

I agree EU cooperation is generally good but its members are politically, culturally & economical much less disparate than the members of ASEAN which range from Singapore to Myanmar.

[gsgs]

Re: On the role of WHO, IHR (2005) & reveres posts

the thread is about Indonesia and that's where ASEAN comes in to play.
ASEAN countries could coordinate their BF-policy.

actually there is very little European colonialism and few problems
arising from it. And if, then because they care too little
about (ex-) colonies , not too much.
It might be better if e.g. the Dutch would care
more about what happens in Indonesia...

WHO could e.g. maybe buy and distribute prepandemic vaccine
in puffer regions or risk-groups now ?!

[JJackson]

Re: On the role of WHO, IHR (2005) & reveres posts

From: Alison Katz
Sent: Monday, January 22, 2007 4:29 PM
Subject: Open letter to Dr Chan
Open Letter to Dr Margaret Chan,
Director-General, World Health Organization
Geneva, January 2007
Dear Dr Chan,
You have taken office as Director-General of the World Health Organization after two discouraging decades in
which the international health authority has been progressively subjected to pressure from powerful minorities,
separated from the people it serves and diverted from its public health mission.
In short, WHO has fallen victim to neoliberal globalization - as have most social and economic institutions
serving the public interest. A number of WHO staff, in senior and less senior positions, have struggled against
the worst excesses of this process, but the damage has been extensive. In addition to the tragedy (and scandal)
of continuing, avoidable disease and death, WHO has lost friends among the people it serves and has gained
rich and powerful "partners" in search of new areas of influence.
Almost certainly, the world's people will force a return to the goal of social and economic justice, and in the
area of health, to the promise of Alma Ata - which was itself explicitly predicated upon a new international
economic order.
"Health for All" became WHO's slogan at the end of "Les Trentes Glorieuses" (1945-1975) - thirty years of
genuine progress towards a fairer - and therefore a healthier - world. This was the era of decolonization, when
the need for redistribution of power and resources, including the rights of peoples to self determination and
control over national resources, was widely recognized and there was strong commitment to universal,
comprehensive public services to meet basic needs for health. A time of optimism, moral vision and genuine
progress.
Optimism was fully justified because the world had (and still has) ample resources to ensure peace, security and
the wellbeing of all. Health for All is no utopia. It was and is achievable even if it is far more ambitious than the
Millennium Development Goals which are - quite literally - a set of half measures defined and delimited by the
G8.
If thirty years is the length of cycles of progress and backlash, with social progress for people always
overtaking, if only by a small margin, the backlash of powerful minorities to maintain their privileges, we are
embarking now on the new 30 year cycle of progress.
And your five years as Director-General (DG) of WHO coincides with that new cycle of progress.
Before I leave, I would like to comment on some of the excellent points you have made in various speeches (1)
since your election, confident that your vision - if you can realize even part of it unimpeded, will reinforce and
accelerate that progress.
1. Inequality should be the focus rather than poverty and insecurity.
You identify poverty and insecurity as two of the greatest threats to harmony which as you rightly state is "a
word at the core of the WHO constitution". You state that "health is intrinsically related to both development
and security, and hence to harmony". The social justice perspective would go further by stating that peace and
security cannot be achieved without justice, and health cannot be achieved without equitable and emancipatory
development.
Our focus today should be on inequality rather than poverty, not because of a preference for the relative over the
absolute, but because unequal power relations are themselves the root cause of both poverty and insecurity, and
because inequality, over and above any level of material wealth or deprivation, is bad for health and for
cohesive, safe, healthy societies. Current inequalities - in which the richest 1% of adults alone owned 40% of
global assets in the year 2000 and the richest 10% of adults accounted for 85% of the world total - are not only
grotesque in their divisiveness, they are lethal.
2. Time to focus attention on the rich but to meet with the poor.
It has become fashionable to focus attention on the poor but to meet - and establish partnerships with - the rich.
In order to address the fundamental problem of inequality, this pattern must be reversed. It is time to focus
attention on the rich and powerful because they are the experts in the mechanisms of unequal power relations
and the architects of policies and strategies which produce, reinforce and accelerate inequalities. Those systems
must be closely examined and opened up to public scrutiny and democratic control. To clarify, this is not a
discourse on good and evil; the issue is one of profoundly antisocial and violent systems not of the use made of
those systems by a handful of rapacious individuals.
Poor people do not attend G8 summits, board meetings of the latest "Global Fund" or "philanthropic"
foundation, let alone the World Economic Forum - where Chief Executive Officers of transnational
corporations are offered even more privileged access to political leaders than they already enjoy. But poor
people also hold meetings and they are represented - if imperfectly - at the World Social Forum (and in national
and regional social fora), in trade union, social and political movements and elsewhere.
As Director-General of WHO, you are committed to "the people of Africa who bear an enormous and
disproportionate burden of ill health and premature death" and you have made this "the key indicator of the
performance of WHO". Your presence at the next World Social Forum on Health (Nairobi 21-23 January 2007
unfortunately coincides with your first Executive Board) and many other such events in the future, would
represent real hope and inspiration for the world's people and an essential counterbalance to high level meetings
with government leaders and their corporate backers/advisers - who are increasingly one and the same.
3. Public-private partnerships or a solid, equitable tax base?
You note that "the landscape of public health has become a complex and crowded arena for action, with a
growing number of health initiatives" and you remind us that WHO is "constitutionally mandated to act as the
directing and coordinating authority on health". As you know, public-private partnerships have become the
policy paradigm for global health work despite the evident conflict of interest which would have outlawed such
arrangements thirty years ago. Agencies and organizations with public responsibilities are "partnering" with the
private sector for one reason. It (appears to have) become the only source of funds. This situation has arisen
because under neoliberal economic regimes, public sector budgets have been slashed and tax bases destroyed.
Those developments are themselves the result of the influence of transnational corporations on governments and
the international financial institutions.
The solution to this problem is not for public bodies to go begging to the private sector, nor to the foundations
of celebrity "philanthropists" with diverse agendas, from industry. The solution is economic justice, including
an adequate tax base, both nationally and internationally, to cover all public services, as well as proper funding
of public institutions such as WHO through regular budgets so that they may fulfill their international
responsibilities unimpeded by corporate interests.
You report that "the amount of money being made available by foundations, funding agencies and donor
governments is unprecedented". This will be entirely positive if you are able to use these funds to pursue your
vision and priorities, as is your right and your duty. It can be argued that if WHO had operated exclusively on
regular budget, even with a significantly smaller workforce but one that was dedicated to WHO's constitutional
mandate, far more progress towards Health for All would have been achieved.
As you say "Primary Health Care (PHC) is the corner stone of building the capacity of health systems. It is also
central to health development and to community health security." PHC will remain health rhetoric if it is not
supported by a solid, equitable tax base and other forms of redistributive justice (debt cancellation and
reparation, fair trade, abolition of tax havens, democratic control of TNC activities etc). WHO itself needs to set
targets for the level of core funding, starting perhaps at 70% of total expenditure, and increasing annually until
undue influence is removed. The private sector has no place in public health policy making at global or national
level. This does not of course exclude responsibly designed interactions as in the past but it does exclude
partnerships because partners must share the same goal.
4. Knowledge for the public good - the world cannot afford corporate "science."
You cite technical authority as one of WHO's four unique assets and you state that "we can be absolutely
authoritative in our guidance" and that "WHO must influence the research and development agenda". WHO's
role as the technical health authority is indeed the jewel in its crown. All the more important then to address the
current crisis in science and reclaim knowledge systems for the public good.
The commercialization of science and the close relationship between industry and academic institutions (2)
should be at the centre of WHO's concerns. In this regard, the public has every right to insist that assurances be
provided that WHO's recent reports on the health effects of Chernobyl and on the safety of genetically modified
foods were researched, developed and produced in full consultation with independent scientists, unimpeded by
other interests.
In relation to the corruption of traditional ideals of science, an editorial in the Lancet reported that "Academic
institutions . . . have become businesses in their own right, seeking to commercialize for themselves research
discoveries rather than preserve their independent scholarly status". Equally worrying is the new trade-related
intellectual property regime which represents an unprecedented privatization of knowledge. Knowledge should
be in the public domain, accessible to all. It must above all be truthful and reliable - a reminder which is not
superfluous today.
Given continuing high levels of avoidable disease and death, alarming resurgence and emergence of old and
new infectious disease respectively, and the devastating effects of environmental degradation and resource
depletion on population health, the world cannot afford corporate "science". As the world's technical health
authority, WHO must take the lead in transforming the way scientific research is conducted and funded and the
way knowledge is acquired and applied.
5. Ethical values and independence of international civil servants.
You state that "We share the ethical foundations of the health profession. This is a caring, healing and sciencebased
profession dedicated to the prevention and relief of human suffering. This gives us our moral authority
and a most noble system of ethical values".
It has not always been easy for staff to stay close to WHO's mandate nor to maintain respect for ethical values
either as public servants or as colleagues during the neoliberal decades. The pressure often proved
overwhelming while the independence of international civil servants was increasingly undermined. As you
know, staff management relations reached a low point and resulted in the first industrial action in WHO's
history in November 2005, a massive work stoppage involving 700 staff. This was despite threats of
disciplinary action including dismissal from the Director-General's Office which reflected not only deep
dissatisfaction on the part of staff but astonishing disregard for international labour standards on the part of a
UN agency.
The work stoppage was not an event to be deplored, lamented, let alone sanctioned.(3) It was a needed signal to
Member States and WHO's wider constituency that radical change was needed.
Staff who struggled against the tide during these past two decades were often "guilty" of their attachment to the
Declaration of Alma Ata which clearly identified social and economic root causes of avoidable disease and
death, placed the debate squarely within international power structures and insisted on a broad public health
perspective which addressed non-health sector determinants of health. They were part of the broad movement
led by civil society organizations promoting a return to the values and principles of Health for All, which was
instrumental in the creation of WHO's Commission on the Social Determinants of Health.
Some, through the Staff Association, were also guilty of revealing to member states, as is their duty, (4)
corruption, nepotism, abuse of rules and procedures and an ineffective internal justice system. In an exemplary
response, members states called for a progress report on staff management relations at the next EB (January
2007) and an audit of all direct appointments at and under the D1 level.
The response however of the last administration was dismal. WHO staff are now represented by a "Staff
Committee" which, apparently in collusion with administration, opposed discussion of the application of
international labour standards (human rights in the workplace) in WHO, at the Annual General Meeting of the
HQ Staff Association. This is an absurd situation, unworthy of a UN agency. Today, there is an opportunity for
civilised and dignified staff management relations in which staff concerns and perspectives are welcomed with
interest and respect. The first step will be to declare that WHO supports not only a rights-based approach to
health but a rights-based organization which fully respects the ILO Covenants. Staff morale and motivation will
soar as will confidence in their leadership.
6. Health for All is value laden and explicitly political.
In discussion with colleagues about all the above concerns, I have often heard that with my views, I should
rather work for an NGO, that my perspective is "political" and that WHO is not an implementing agency. My
response to the first comment is that WHO staff should surely be more committed to the values and principles
of Health for All than staff of any other organization, just as all UN staff should be at the frontline of the
defense of the UN Charter.
My response to the second comment is that health is political and that the PHC approach and Health for All was
and is an explicitly political project - as is the neoliberal project for health and health care. Today's international
health establishment denies any political values, intentions or interests and presents itself as neutral, objective
and armed with scientific facts. But scientific objectivity requires awareness and acknowledgement of
underlying values and principles. The States Parties to the Constitution, in line with the Charter of the United
Nations accepted a set of nine ethical principles when they established the World Health Organization. This is
the source of our "moral authority" and it is a value laden and highly political document - if one accepts that
politics is about the organization of societal structures and functions, in particular in relation to the distribution
of power and resources, for the benefit of its members.
My response to the third comment is that although WHO is not an implementing agency, it has a clear advocacy
role in terms of identifying and promoting policies and strategies - on the basis of serious science and sound
evidence - that will ensure the meeting of basic needs for health, among other things.
7. Conflicting loyalties.
In the neoliberal decades, WHO staff, and other international civil servants, have found themselves in an uneasy
position with conflicting duties of loyalty on the one hand to WHO's constitutional mandate and the UN
Charter, and on the other hand - as WHO is an intergovernmental agency - to member states and current office
holders and their interpretation of these mandates. The most obvious examples are UN sanctions and the
invasion of Iraq which have caused public health catastrophes.(5) These actions have been qualified as war
crimes and genocide respectively.(6)
Less spectacular examples of conflicting loyalties relate to certain policies and strategies which do not make the
headlines but which cause illness and death on a daily basis and an even larger scale. WHO has failed to
denounce, in the strongest possible terms, unfair rules of trade and commerce, odious debt, ruthless
liberalization of economies, privatization of public services and continued exploitation of people's national
resources. This is despite ample evidence that these processes create poverty and inequality, interfere with
people's capacity to provide themselves with adequate supplies of food and water, and maintain more than half
the world's people in unspeakably miserable living conditions.
At least 10 million children die every year and the vast majority of those deaths are avoidable. Life threatening,
structural violence requires principled, unambiguous resistance not cautious admonitions, let alone timid
acquiescence.
We live in exceptional times when leaders of powerful nations, who scarcely represent their own people let
alone all member states, embark on illegal action leading to death and destruction and when transnational
corporations, in collusion with international financial institutions - with no democratic legitimacy or
accountability - are allowed to impose policies which have been shown to have devastating effects on
population health. Should staff choose loyalty to current office holders and selected member states rather than
loyalty to the mandate of their organization and the world's people who are often, very poorly represented by
their governments? Should respect for human rights and confidence in our own moral judgment tip the balance
in these conflicting loyalties?
8. Perhaps exceptional responses are required in exceptional times.
"The way in which citizens of the rich countries currently live their lives is, on the whole, morally acceptable".
(7) Recognition that "everyone's favourite prejudice" is profoundly wrong is fundamental to the struggle for
social justice and Health for All.
WHO (and other UN) staff may be misinformed (by failing to consult alternative sources of information) and
disinformed (by accepting la pens 饠unique of mainstream and conventional sources of information). However
none of us can claim lack of access to full information. It is time to consider whether the way in which UN and
WHO staff serve the UN Charter and WHO's constitutional mandate, respectively, is, on the whole, morally
acceptable or whether this belief is "our favourite prejudice".
Dr Chan, the vision you have articulated is exemplary and an inspiration to staff. But you will need them to
summon up the courage of their convictions, stand strong in the face of powerful opposition, and keep close to
WHO's constitutional mandate, if they are to assist you in its realization.
Sincerely,
Alison Katz
Notes
1. Speech to the World Health Assembly, 9 November 2006 as DG elect and Address to WHO staff, 4 January
2007, as DG. http://www.who.int/dg/speeches/2007/.../en/index.html
2. This section is drawn from the Convention on Knowledge, Institute of Science in Society. www.isis.
org.uk/conventiononknowledge.php
3. My post was abolished three weeks after the work stoppage and three weeks before the normal renewal of my
two year contract, after 17 years service. This has been qualified as retaliation for industrial action (a violation
of human rights) by Swiss unions and staff association lawyers.
4. According to an Executive Board Resolution EB91/1993/REC/1.
5. Just prior to February 2003, WHO was involved in preparations for post-invasion emergency health
measures. In the interests of contributing to the prevention of violence rather than merely participating in the
"mopping up operation" staff asked administration if they might circulate a petition in support of the UN
Charter (available on request). They were informed that if they did so they would be asked to present their
resignations.
6. See for example Initial Complaint prepared for the First Hearing by staff of the International War Crimes
Tribunal http://deoxy.org/wc/warcrim2.htm and report on effects of UN sanctions

http://www.geocities.com/iraqinfo/sanctions/holocaust.html

7. Thomas W. Pogge, World Poverty and Human Rights, Polity Press 2002.

[JJackson]

Notes on the IHR(2005) 2nd. Edition

As there is some interest, in light of the current Ebola pandemic, in what the WHO can and can not do I thought a review of some of the relevant articles might be helpful.

The problem with these international legal documents is they are not straight forward to read as most articles include this kind of thing

"WHO shall use information received under Articles 6 and 8 and paragraph 2 of Article 9 for verification, assessment and assistance purposes under these Regulations"

when you then look up the referenced articles they send you off to somewhere else. What I have done in the text box below is to condense the key sections into a, hopefully, more intelligible form.

Obviously this has a cost in completeness and if anything is critical to your particular interest you will still need to refer back to the original text. This link is to the IHR(2005) 2.0 full text pdf.

The early IHRs listed the reportable diseases but this became an increasingly obvious problem with zoonotic emergence as with HIV and SARS. To overcome the limitations of enumerated threats a decision making flowchart has replaced them and this is to be found as Annex 2.
Where exact wording is important I have used the original text and placed it in italics within quotation marks.

PART I – DEFINITIONS, PURPOSE AND SCOPE, PRINCIPLES AND RESPONSIBLE AUTHORITIES
Part one mainly defines terms, including
“public health emergency of international concern means an extraordinary event which is determined, as provided in these Regulations:
(i) to constitute a public health risk to other States through the international spread of disease
and
(ii) to potentially require a coordinated international response”

PART II – INFORMATION AND PUBLIC HEALTH RESPONSE
Article 5 - Surveillance
1 Build detection and reporting capacity within 5 years.
2 Mechanism for States to ask for an extension if they cannot build detecting/reporting in time.
3 Mechanism for States to ask WHO for help in setting up these systems.
4 WHO undertakes to monitor potential health threats and notify States as needed.
Article 6 - Reporting
1 Obliges states to report communicable diseases within 24hrs. (Annex 2 is a decision tree which determines if a disease must be notified).
2 Obliges states to keep sending situation updates.
Article 7 – Information Sharing
Obliges states to report any thing weird going on
Article 8 – Consultation
Allows states to report things that were not mandatory under Annex 2.
Article 9 – Other reports
1 This allows the WHO to receive reports from non-state sources about a potential problem. They are then obliged to evaluate the report and pass on their findings, and the original report, to the effected state before taking any other actions. “To this end, WHO shall make the information received available to the States Parties and only where it is duly justified may WHO maintain the confidentiality of the source” (whatever that means)
2 Gives the state 24hrs to respond to the allegations.
Article 10 - Verification
1 Obliges WHO to “request” verification of any alleged event.
2 Obliges the State to respond within 24hrs
3 Obliges the WHO to offer its help in evaluating the situation/response of the state to the alleged problem.
4 “If the State Party does not accept the offer of collaboration, WHO may, when justified by the magnitude of the public health risk, share with other States Parties the information available to it, whilst encouraging the State Party to accept the offer of collaboration by WHO, taking into account the views of the State Party concerned.”
Article 11 – Provision of information by WHO
1 Once the WHO is made aware of a problem by any of the routes covered above it is obliged to pass this on quickly to All States and “as appropriate, to relevant intergovernmental organizations” “in confidence”
2 Binds the WHO to confidentiality unless either released by the State in question, meets ‘health emergency of international concern’ criteria, has spread into another State, or there is evidence it is not likely to be controllable.
3 Obliges WHO to let the State know that it is releasing information.
4 Gives the WHO the option of speaking publicly if it is already in the public domain and “there is a need for the dissemination of authoritative and independent information”
Article 12 – Determination of a public health emergency of international concern (PHEoIC)
1 Gives the DG the authority to decide if an event constitutes a PHEoIC
2 Obliges the DG to consult with the affected state and if both agree it meets the criteria the DG gets advice from the ‘Emergency committee’ (defined in article 48) on recommendation to be instituted.
3 Covers the event of the affected State disputing the DG’s determination in which case it is adjudicated by an ‘Emergency Committee’
4 Gives a fairly broad list of factors the DG may use in coming to her determination.
5 Covers the ending of a PHEoIC if the DG and State agree.
Article 13 – Public health response
This section covers the offer of assistance by WHO to an affected State – which it is not obliged to accept.
Article 14 - Cooperation of WHO with intergovernmental organizations and international bodies
This section sets up terms of cooperation with NGOs and intergovernmental bodies.

PART III – RECOMMENDATIONS
Part 3 enumerates a number of recommendation options like “implement isolation or quarantine”

PART IV – POINTS OF ENTRY
Covers ports, airports land border crossings etc.

PART V – PUBLIC HEALTH MEASURES
Covers what a State may, and may not, demand of a traveler. In general they can ask for proof of vaccination, travel history etc. But cannot demand a medical examination or perform a vaccination without consent (there are exceptions)
Chapter IV – Special provisions for goods, containers and container loading areas

PART VI – HEALTH DOCUMENTS
Basically says States must accept vaccination certificates. Also lays out more rules for ships and planes.

PART VII – CHARGES
Lays out what a State may or not charge a traveler for in terms of heath checks. If you are isolated or quarantined they can not charge you for it and are obliged to feed you etc.

I am not going to bother with the rest of the articles as I do not feel they are very interesting apart from Annex 2 which is at the core of IHR and needs to be looked at in the original or the flowchart can be found here and Appendix 2 in which a number of States opt out of certain sections.
The principal one being the US. “it is the United States' understanding that any notification that would undermine the ability of the U.S. Armed Forces to operate effectively in pursuit of U.S. national security interests would not be considered practical for purposes of this Article”

[Ray]

Re: On the role of WHO, IHR (2005) & Reveres' posts

Couple of questions:

Who does the testing? Do most member countries now have their own testing capability without the need for WHO? So they can report that the testing has been done and it is negative?

The testing, results of the tests, this can all be done "in confidence" (or this information is released into the confidence of other member states for security?) but there is no obligation to release info to the public.

WHO is continually stating that there is underreporting of cases and deaths--according to the above, this may not necessarily mean just cases in known affected countries.

Is this why we've heard no updates (other than the positive wife and sister) on the 65 "high-risk" exposures to the Nigerian doctor? They aren't required to make public positive tests?

[JJackson]

Re: On the role of WHO, IHR (2005) & Reveres' posts

Couple of questions:

Who does the testing? Do most member countries now have their own testing capability without the need for WHO? So they can report that the testing has been done and it is negative?

The testing, results of the tests, this can all be done "in confidence" (or this information is released into the confidence of other member states for security?) but there is no obligation to release info to the public.

WHO is continually stating that there is under-reporting of cases and deaths--according to the above, this may not necessarily mean just cases in known affected countries.

Is this why we've heard no updates (other than the positive wife and sister) on the 65 "high-risk" exposures to the Nigerian doctor? They aren't required to make public positive tests?

Article 5.1 - which I truncated to "Build detection and reporting capacity within 5 years" - sends you to Appendix 1 for a more detailed list of things you need to do. Section 6 of this requires, at a national level, "(b) to provide support through specialized staff, laboratory analysis of samples (domestically or through collaborating centres) and logistical assistance (e.g. equipment, supplies and transport);" for countries without a national reference lab capable of safely dealing with Ebola samples the WHO has regional collaborating centres which will take samples for testing. A searchable database of these centres can be found here.

As to the second part of your question I do not think the WHO are hiding anything reported to them as they are released from this obligation under Article 11 sections 2 and 4.

2 Binds the WHO to confidentiality unless either released by the State in question, meets ‘health emergency of international concern’ criteria, has spread into another State, or there is evidence it is not likely to be controllable.
3 Obliges WHO to let the State know that is releasing information.
4 Gives the WHO the option of speaking publicly if it is already in the public domain and “there is a need for the dissemination of authoritative and independent information”

The exact text of 2.4 includes "WHO may also make it available to the public if other information about the same event has already become publicly available". As I pointed out in the first post in this thread law needs precedent and the bolding (which is mine) leaves open the definition of 'the same event' - which I would interpret as the whole Ebola outbreak - but I am sure you could find a lawyer who would argue for a less inclusive definition.

The under reporting is likely to be due to the fact the HCWs on the ground are swamped and consequently turning away infected individuals who are probably positive but never got into a treatment centre so never got evaluated or tested. In the Nigerian case I would suspect the traced contacts are still under observation but no further report would be expected unless they become symptomatic. In this case I would go with 'no news is good news'.

Again just my opinion/understanding of the situation.