Introductory remarks prepared in advance of the informal meeting of participants in Health Action International with senior representatives of the World Health Organisation, Geneva, 9 October 1998

I speak first for our group, but not foremost. It is beyond my terms to speak for any one of us, beyond thanking you all (WHO) very much for this opportunity to share ideas about matters of great concern. We greatly value this time we have to meet, listen and discuss - so much so that I shall not dwell on niceties, but will dive straight in.

Our group of ten assembles from four continents and twice as many countries. This underlines that we are not, in any traditional sense, close colleagues. We are a handful of exemplars (rather than representatives) of a network of mainly small, mostly charitable groups operating in the same field. We work at the interface of health and development and we collaborate mainly in gathering, analysing and communicating good evidence of better ways to health.

To emphasise that I alone am responsible for what I say, I will confess to meeting several members of our group, for the first time, only last night. This may seem strange, but is almost inevitable - because each of us, in turn, represents only a fragment of a large network of many other individuals and small organisations, with the same broad focus of concern. What is this concern? I'd like to read this statement our group agreed late last night:

"Our concern is health. We are lobbyists for equity in access to health - especially concerned about extending access to essential drugs and promoting the rational use of medicines everywhere. Our work centres on reaching decision-makers with a convincing case, and drawing their attention to human need - trying to help break the vicious cycles which link ill-health, poverty, and other manifestations of arrested human and social development. Fundamental to our concern is the need for sustainable health systems, giving more access to basic health. More needs to be done. We want to help do it."

There are three other things I should tell you about this statement. First, I drafted it last weekend, exactly as it reads, having discussed it with nobody. Secondly, before this moment, I have told no one connected with our group how this statement was put together. I apologise to my colleagues for this, but the need for blindness will be clear from my third point - that except for the odd word (notably the descriptor "lobbyists"), every element and sentiment in this statement was lifted verbatim from a speech given in Washington, last month, by the Director-General of WHO. In other words, we have closely linked concerns. We all feel good about describing our objectives and concerns in exactly the terms Dr Brundtland used.

Moreover, the whole business of "reaching decision-makers with a convincing case" is exactly what lobbying is, or ought to be. WHO is certainly something of a lobbying organisation, and so it needs to be. And in this and its other roles - as Dr Brundtland also said in her speech - WHO needs to "reach out" and "engage" with stakeholders, embracing "all potential contributors to better health - public sector, private sector or NGOs". I am sure she was not referring here only to NGOs "in Official Relations with WHO". Though we would welcome an embrace, suffice it that we seek good working relations with WHO, and want to contribute as constructively and vigorously as possible to help make better health a global reality.

HAI roles  I imagine it was left to me to open this discussion both because, and in spite, of being older/greyer than the average collaborator in Health Action International, the group through which we convene. Being one of the several grandparents of HAI, I was professionally active in an age of uninhibited hope - the era of Kissinger's dream, ("within a decade no child will go to bed hungry", 1974 ) and the days of North South and H2000, beyond. Since then, the struggle has intensified within me, to balance wisdom and anger with impending obsolescence.

So it helps to remember the good bits, and one was the founding of HAI. My small research unit, Social Audit, was much involved in helping to set up the original HAI framework, here in Geneva in 1981. The place and date were no accident: this was also the time of the setting up of WHO's Action Programme on Essential Drugs. HAI groups have worked hard to promote rational drug strategy, ever since.

At the core of our operation, the central focus has always been on WHO's work in this field. This will surely be so in future, and I believe it right it is. Lobbyists with Health for All in mind need to focus, not on trying to do the job themselves, but on encouraging others to get the job done. To this end, HAI people have contributed over the years to promoting awareness of the need for, and obstacles to world health - not only in their own fields and lands, but by joining more formally in many related WHO initiatives.

I was one of several participants from HAI at WHO's 1985 Nairobi conference on the rational use of drugs and was subsequently involved in some of the initiatives arising - eg in helping to develop guidelines for national drug policies and ethical criteria for advertising. However, I should stress that this counts almost as fleeting contact with WHO compared with that of many colleagues.

For example, every year or two, since 1981, a HAI team of usually around a dozen people, has converged on Geneva for two weeks to be present during the World Health Assembly - but I have never been. But I can tell exactly what they were up to: "reaching decision-makers with a convincing case"

In the course of this meeting, you will hear about some of the many other ways in which HAI people have worked with, through and around WHO - one way or another seeking to promote Health for All. Advocacy is the common denominator, but HAI people engage in many different areas, some outside the health system. For example:

The breadth of our involvement, geographic spread, and limited resources, all preclude tight, centralised organisation or any institutional structure. However, rapid electronic communications increasingly keep us closer and closer in touch - and enable us to reach a growing band of others much concerned.

Re: the private sector   One matter I am sure will be discussed today is the pharmaceutical industry, and its impact on world health. I know a bit more about this than I did when last in Geneva, not least because, over the past two or three years, I have been involved in small private seminar series with top executives in a leading multinational pharmaceutical company. Both sides learned much - perhaps above all, about the importance of listening and the value of exposure even to almost unthinkable ideas.

The second thought is about what I see as a moral obligation. If the pharmaceutical industry is to enjoy all the rights, privileges and protections that give it dominant wealth in the health sector, it also falls to it to attend conscientiously to real health needs. Donations to good causes are not enough; commitments to procure health must go deeper, and outright self-interest must be curbed. Medicinal drugs are not like other commodities, and the companies that make them have special reason to be called to account.

I do not think this idea is too far removed from some key points in the Director-General's recent Washington speech - and I am sure there is strong support in our group for the spirit of what Dr Brundtland said about the relationship between commerce, medicines and health. We must not forget how important drugs may be, but let us not succumb to any exaggerated view of what can and can't be achieved by using them:

"The performance of market forces has enormously increased productivity in many sectors of the world economy. The health sector is also benefiting. But just as the private for-profit sector may be good at allocating resources cost-effectively, it is seldom the key provider of primary health care or the guarantor of securing health services to the poor. Neither will it ensure universal access…"

"At the same time, to meet pressing public health needs we need new drugs and vaccines … To develop new drugs we need innovative research industry, with appropriate incentives for innovation and protection of intellectual property rights."

Against this background, also bearing in mind how many "important determinants of better health lie outside the health system", it is clearly very important for WHO to engage with the private sector in constructive dialogue. There must, however, be doubts about the extent to which it can be appropriate for WHO to rely on company funding for its programmes. Underlying my concern is the continuing freeze on levels of contributions from members states, and the rapid accretion of wealth and power in the private sector. Of the 100 richest economic units in the world today, 40 are multinational companies. Fragmentation of national sovereignties and rapid development of world markets means wealth is increasingly and rapidly moving to the private sector - but without adequate democratic safeguards and systems of accountability to go with it.

HAI welcomes the safeguards against possible personal conflicts of interest, introduced by the new WHO administration on taking office. However, I think there is much more to be done, especially in relation to company funding of agency programmes. Briefly, there is no such thing as a free lunch, and existing safeguards look thin. Would I, as a UK citizen, be concerned if pharmaceutical companies funded initiatives in the Department of Health, albeit at arms length from drug control? Indeed, I would. There are risks - and I hope that in this or some future meeting, we shall be able to discuss what they might be and how to avoid them.

Democratic imperatives   I have discussed elsewhere the significance and origins of the sibling relationship between good medicine and healthy democracy. Each reinforces the other, and good health is an expression of both. Market forces are bound to some extent to steer the quality and availability of good health, but must not be allowed to determine them.

Good science and its honest application also depend on the two great pillars of democracy, openness and accountability. They underpin effective participation and partnership, and the integrity of power depends absolutely upon them. Accepting such disciplines does mean taking some risks, but the great benefit is pubic confidence and support.

I very much hope this meeting marks the beginning of, whatever else, some growing trust between HAI and WHO. I hope we can learn to collaborate better: it would be futile not to, when all parties have their eye on the same goal. As to our efforts at lobbying - even when directed squarely at WHO itself - I hope you and your colleagues at WHO will at least appreciate where much of the inspiration came from.

I can best explain what I mean here by closing with an inspired thought. It comes from a 1983 WHO Expert Committee report on health education, and I have quoted in just about every major talk or piece of writing over the past decade or more. It is a great guiding principle, but still too much a dream:

" … science and technology can contribute to the development of health standards only if the people themselves become full partners of the health care providers in safeguarding and promoting health … people have not only the right to participate individually and collectively in the planning and implementation of health programmes, but also a duty to do so"

I am sure we shall make the most of this meeting, bearing this in mind.

Charles Medawar
4 October 1998

The speech referred to, by the WHO Director-General, Dr Gro Harlem Brundtland, was her address to the Regional Committee for the Americas, Washington DC, on 21 September 1998. Fulltext can be seen at http://www.who.int/inf-dg/speeches/english/amro_21091998.html   For more information about the WHO/HAI meeting, please see the Health Action International website - http://www.haiweb.org - or the e-drug bulletin board, accessible via e-drug@usa.healthnet.org

 

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