World Health Organization : The mandate of a specialized agency of the United Nations

The third part of this contribution is dedicated to the analysis of some of the numerous activities carried out by the World Health Organization, and it represents an exemplification of what has been previously described. In the first part, I have tried to delineate the basic characteristics of the WHO as an institution. The second part has been a description of the mandate of the Organization starting from its nature as a specialised agency of the UN. The conclusion was that this position makes the WHO an Organization with an extremely broad mandate.

The third part, therefore, wants to be a further demonstration of such a characteristic, showing how a broad range of activities corresponds to a broad mandate. As an example, three activities in which WHO is involved will be presented. The choice was based on the principle of variety, and also on the relationships developed during my stay at the WHO. The activities taken into consideration are:

As the reader will realise, the following initiatives are totally different from each other and, at first glance, they do not seem to have anything in common. Nevertheless, they are all carried out by the same agency, and they all fall into WHO's mandate.

"The country needs, and unless I mistake its temper, the country demands, bold, persistent experimentation. It is common sense to take a method and try it; if it fails, admit it frankly and try another. But above all, try something"
Franklin Roosevelt

Tuberculosis is a chronic bacterial infection, almost always of the lungs, caused by Mycrobacterium tuberculosis[1]. The term that is currently used has a French origin. It comes from the word 'tubercules' which indicates the small and round lesions distributed over affected parts of the body.

Tuberculosis is one of the most ancient diseases. Deformities, presumed to be TB-induced, were found in the mummified skeleton of an Egyptian priest from Ammon who died around 3,400 B.C. Hippocrates, in the Golden Age of Greece, used the word 'phthisis' (consumption) to describe the state associated with TB.

However, only in 1882, the German pathologist Dr Robert Koch identified the cause of tuberculosis in the TB bacillus, 'Mycobacterium tuberculosis'. Twenty five years later, the first vaccine was created and was administered to infants during their first year of life. This vaccine was called 'BCG' after the name of the scientist who developed the bacillus, Calmette and Guerin. However, this vaccine was proved ineffective against the most common pulmonary form of TB[2].

The first real medical improvement was introduced in 1944: the chemotherapy using the single antibiotic drug streptomycin to treat active TB. This was the first successful treatment and it demonstrated that the TB bacillus was not invincible[3].

Although drugs to cure TB have been discovered, people continue to die of it. Tuberculosis kills approximately 2 million people, and it infects nearly 1% of the world's population each year[4]. Every day more than 23,000 people develop active tuberculosis and close to 5,000 die from the disease[5]. Every second someone in the world is newly infected with TB[6]. The global epidemic is growing and becoming increasingly dangerous. The number of new TB cases augmented 6% each year between 1997 and 1999, from 8 million to 8.4 million world wide[7]. One third of the world's population is currently infected with the TB bacillus. 5-10% of people who are infected with TB become sick or infectious at some time during their life[8]. It is estimated that between 2002 and 2020, approximately 1,000 million people will be newly infected, over 150 million people will get sick and 36 million will die of TB[9].

TB is mainly a disease of poverty: it affects the poorest people in the world's poorest countries. A 98% of the 2 million annual TB deaths, and 95% of the 8.4 million new TB cases, take place in developing countries. The 22 high-burden countries are Nigeria, Ethiopia, South Africa, Congo, Kenya, Tanzania, Uganda, Mozambique, Zimbabwe, the Russian Federation, Brazil, India, China, Indonesia, Bangladesh, Philippines, Pakistan, Vietnam, Thailand, Myanmar, Afghanistan, Cambodia. To give some numbers: about 2 million TB cases per year occur in Sub-Saharan Africa, around 3 million cases per year occur in South-East Asia and over a quarter of a million of cases per year occur in Eastern Europe[10].

In these poor countries, TB causes an estimated economic costs to poor households of more than US$ 12 billion a year[11]. Basically, three to four months of lost work time, and 20% to 30% of lost income. Moreover, about 15 years of income is lost due to the premature death of a member of a family. In low and lower-middle income countries, TB generally afflicts the most economically active segment of the population. Generally 75% of the 2 million people dying annually are between the ages of 15 and 54[12]. Therefore, economic development and TB are strictly linked. The result is a vicious cycle, where TB retards development and lack of development spreads TB.

TB usually affects the most vulnerable sectors of a population. Approximately 35 million women develop active TB every year. Men are more likely to have latent TB infection, whilst women often proceed from infection to active disease, and they rarely receive diagnostic and treatment services. Furthermore, a quarter of a million children still develop TB every year. The fact is that they are subjected to infection from household contacts: many of the children get infected by parents or other relatives with active infectious TB. The transmission of TB is also very common in environments as prisons, shelters for homeless, mines, military barracks, refugee camps, etc[13].

In the last years, the situation of the epidemic has been worsened by two further factors. One is the overlapping epidemics of TB and HIV/AIDS, and one is the emergence of drug-resistant TB. As far as it concerns the co-infection of TB and HIV/AIDS, it is not difficult to understand that each disease speeds up the other's process. HIV actually increases the risk of developing active TB by weakening the immune system. At the same time, the presence of other infections, as TB, can result in more rapid progression of HIV infection to AIDS[14]. TB is a leading cause of death among people who are HIV positive. It has been estimated that approximately 11% of AIDS deaths worldwide depend on TB infection. In 2000, about 12 million HIV-infected people worldwide were also co-infected with TB. About 70% of co-infected people live in Sub-Saharan Africa, 20% in Asia and 8% in Latin America[15].

Regarding to drug-resistant TB, it basically derives from malpractice in the treatment of TB[16]. The fact is that "from the scientific perspective, modern medicine's role is to cure disease. However, from the pathogen's point of view, it is all about survival. To paraphrase Nietzsche, whatever does not kill them, makes them stronger"[17]. Therefore, from a certain point of view, poorly supervised or incomplete treatment of TB is worse than no treatment at all. If people do not complete the standard treatment regime, or are given the wrong treatment, they may remain infectious. The bacilli in their lungs may develop resistance to anti-TB drugs, and they may become incurable. A particularly dangerous type of drug-resistant TB is multidrug-resistant TB (MDR-TB), which is defined as the disease due to TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs[18].

Once given an overview of the enemy to be defeated, I will show some of the interventions taken by the World Health Organization to combat this terrible threat. It is actually possible to trace an evolution of WHO policies for TB control. The constant of this process is a continuous swinging back and forth between vertical and horizontal approaches, between specialised and integrated methods.

It is not in the scope of this contribution to describe every single step[19] of this development. Therefore, I will just take into consideration two of the most recent actions taken by WHO for the control of TB. They constitute respectively an example of a vertical[20] and specialised[21] approach, and of a horizontal and integrated approach: DOTS and the Global Partnership to Stop TB.

In 1991, the 44th WHA adopted, through a resolution, the strategy which provided a new framework for effective tuberculosis control[22]. This strategy, which will be then labelled DOTS (Directly Observed Therapy, Short-course), is composed of five essential elements. The first two elements are technical and the other three are managerial[23].

During the 1990s, DOTS was adopted by several countries. While less than 10 countries had a proper system of TB control in 1990, 127 countries, among which the 22 high-burden countries, had adopted DOTS by 1999[25] and 148 in 2000[26].

In 1993, the WHO declared TB a global emergency and tried to expand DOTS as much as possible. The WHO was the leading Organization in taking this action: it would define the basic guidelines, it would directly act and it would be involved also with the monitoring. Nevertheless, the epidemic increasing danger showed that the intervention of a single actor was not sufficient. The "WHO was not enough", as a member of the Secretariat told me[27].

From 17 to 19 March 1998, an ad-hoc Committee on the Tuberculosis Epidemic was convened in London to discuss the modality for widening TB control, and to find any kind of feasible solution. The report of the meeting testified WHO's recognition of the fact that TB could not be effectively faced without a consistent alliance with other numerous actors. The report recommended that political will and commitment to ending the TB epidemic was needed at the highest level of the organisations concerned: the WHO itself, the World Bank, other multi-lateral financial institutions, bilateral development assistance agencies, NGOs, philanthropic institutions, national governments, the private sector and civil society[28]. The report also encouraged donor's support to countries, to do better economic analysis and to do better economic planning to overcome financial constraints[29].

To respond to such a challenge, Dr Brundtland launched the Global Partnership to Stop TB[30] , in November 1998, in Bangkok. The founding members of the Stop TB Initiative were initially the American Lung Association, the American Thoracic Society, Centres for Disease Control and Prevention, International Union against TB and Lung Disease, Royal Netherlands TB Association and the World Health Organization[31]. Nowadays, the partnership counts approximately 200 organisations working together for a single aim: the elimination of TB. They are organisations of different types: country partners, international organisations, public and private donors, governmental and nongovernmental organisations and academic institutions[32].

The Global Partnership to Stop TB has also established a structure to ensure the effective coordination of multiple and various efforts. The structure is composed of a Partners' Forum, a Coordinating Board, working groups and a Secretariat[34]. I will briefly deal with each one of these components, bearing in mind that WHO is just one of the several partners of the Stop TB Partnership.

The comparative advantage of the WHO in such a vast partnership is represented by two essential functions. The first one is to be a strong leading agency, providing guidance on global policy and providing a representative to the Stop TB Coordinating Board. The second one is, in fact, to house the Stop TB Partnership Secretariat[41].

A further step towards an improved control of TB was the conference on 'Tuberculosis and sustainable development' convened in Amsterdam on 22-24 March 2002. The Amsterdam Declaration to Stop TB, adopted on the World TB Day, was the immediate result of the conference. The meeting was attended by high-level representatives of UN system agencies, technical agencies and donor countries, but fundamentally by the Ministers of Health, Finance and Development Planning from 20 of the 22 high-burden countries. The declaration is, therefore, the voice of the countries in major need. The document expresses "the urgent need for accelerated action against tuberculosis, a major killer of our people and a significant impediment to the development of our nations"[42]. The declaration also recognises that "the global tuberculosis emergency is much more than a health concern; it is a complex socio-economic problem that impedes human development, and cannot be defeated by the health sector acting alone"[43]. Therefore, the ministerial representatives of the high-burden countries "call upon international development partners from the UN system, Bretton Woods institutions, bilateral agencies, NGOs and foundations to increase their support to tuberculosis control efforts"[44]. Furthermore, the 20 high-burden countries asked for an increase in the availability and access to drugs, and for the acceleration in the research and the development of new tools, as diagnostics, drugs and vaccines. This document, thus, represents a turning point, a scaling up and speeding up of efforts towards the elimination of TB.

The response to the requests of those countries came in October 2001, during the First Partners' Forum in Washington. During this convention, the partners expressed their commitment to operationalise the Amsterdam Declaration to Stop TB. In the Washington Commitment to Stop TB, the partners promised "to undertake urgent and accelerated action against tuberculosis over the next 50 months; to intensify efforts to reach the global targets for tuberculosis control by 2005; to detect 70% of people with infectious tuberculosis, and successfully treating 85% of those detected; and mobilising additional resources through increasingly coordinated efforts"[45]. As direct consequences of this commitment, two initiatives were promoted in this occasion: the Global Plan to Stop TB[46] and the Global Drug Facility[47].

As far as it concerns the first initiative, the Stop TB Coordinating Board had already called for development of a strategic plan for the Stop TB Partnership at its February meeting in Bellagio, in 2001[48]. This plan should also take into account the request of the Amsterdam Declaration. The Global Plan to Stop TB was, therefore, subsequently prepared by a team from Partners in Health and the Stop TB Partnership. It was funded by the Open Society and Institute and USAID, and it incorporated the contributions from over 150 experts in TB control, public health and development around the world[49].

The Plan, launched at the First Partners' Forum in October 2001, describes the strategy and resources needed over the next five years to move towards a TB-free world. According to this plan, the Stop TB Partnership should orient its work towards four main objectives:

Regarding to the Global Drug Facility, it is a further initiative of the Stop TB Partnership that followed the urgent call from the Ministers of the high-burden countries at the Amsterdam Conference[51]. This initiative was launched before the Global Plan to Stop TB, on World TB Day, in March 2001. The Global Drug Facility is aimed to secure the access to high-quality TB drugs to accelerate DOTS expansion, by providing drugs for at least 10 million TB patients by 2005, and by treating 45 million patients by 2010[52]. The goals of the Global Drug Facility are:

The achievements of such a strategy have proved its effectiveness. Just to give some data, in its first year, the Global Drug Facility has processed applications from 38 countries, approved 23 eligible countries and begun drug delivery to 10 of these. It has approved a total of 1,144,905 patient treatments. It has brought a remarkable reduction in drug prices of about 30%[54].

Having gone through the various steps, it becomes clear that the WHO maintains a fundamental role in the fight against TB. In particular, as one of the main actors of the Stop TB Partnership, the WHO openly recognises the necessity of a global alliance in order to effectively control the tremendous disease.

In the previous paragraphs, I have analysed the gravity of the TB epidemic and the effort of the World Health Organization to face it, referring also to its cooperation with the multiple actors of the Stop TB Partnership. Once the problem and response have been delineated, one could ask whether WHO's action to Stop TB fits within the Organization's mandate and in which terms.

As a specialised agency of the UN, the WHO has a fundamental role towards achieving the Millennium Development Goals. In particular, the sixth of the MDGs states to halve and begin to reverse the spread of HIV/AIDS, and the incidence of malaria and other major diseases by 2015. The reference is to diseases such as TB, and, in fact, the indicators to monitor progress are directly linked to it. Indicator number 23 is "the prevalence of rate associated to tuberculosis"[55], and number 24 is "the proportion of tuberculosis cases detected and cured under DOTS"[56]. With its Stop TB Department and its participation to the Stop TB Partnership, the WHO responds to its mandate, where it is defined by the UN main goals.

The other side of being a specialised agency of the UN is to maintain a certain degree of autonomy, which makes the WHO an Organization with a high degree of independence. The Stop TB activity perfectly fits in WHO's mandate also under this perspective.

The concept of health as a human right and the 'Health for All' idea as the main objective of the Organization, according to its Constitution, want the WHO to act in order to obtain a TB-free world. If the TB control is a basic human right[57], and if TB is a disease which mainly afflicts the poor and vulnerable, the WHO should intervene, by itself or in partnership, in order to offer all the necessary help and resources to fight TB.

Moreover, if one remembers, the corporate strategy for the WHO Secretariat, in the strategic direction 1, states that the WHO should work in order "to reduce excess mortality, morbidity and disability, especially in poor and marginalized populations"[58]; in strategic direction 3, underlines WHO's function in "developing health systems that equitably improve health outcomes, respond to people's legitimate demands, and are financially fair"; and in strategic direction 4, reports that the WHO should "promote an effective health dimension to social, economic, environmental and development policy"[59]. Looking at the strategic directions that should guide the work of WHO Secretariat, the action to Stop TB seems to be perfectly coherent. Promoting the control of TB is, in fact, a fundamental element for obtaining poverty alleviation, health systems improvement and economic development.

Finally, if one looks at the programme budget for the biennia 2000-2001[60], 2002-2003[61] and 2004-2005[62] (Table 1), it is evident that TB represents one of the priorities set by the Organization. The increasing amount of resources allocated to TB activities shows the strong commitment of the Organization towards this goal.

Moreover, the recent election of the Director of the Stop TB Initiative, Dr Jong Wook Lee[63], to the Director-General post, is likely to bring a further involvement of the WHO in these activities. Will this mean a reduction of funds and a lack of interest for other kinds of activities, as the ones which will be presented in the following two chapters? It is now too early to give an answer to this question.

For the meanwhile, it is evident that the activities to Stop TB conducted by the WHO, in collaboration with the Stop TB Partnership, totally fit within WHO's mandate, as this is defined by WHO's nature of specialised agency.

[1] For complete information, see Zand, J., Spree, A.N., LaValle, J.B., Smart medicine for healthier living, Avery Publishing Group, New York, 1999, p. 565

[2] TB: towards a TB-free future, Document WHO/CDS/STB/2001.13, WHO, Geneva, 2001, pp. 10-11

[3] ibid.

[4] Tuberculosis, Fact Sheet No. 104, available at www.who.int/mediacentre/factsheets/who104/en/print.html

[5] The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, p. 27

[6] Tuberculosis, Fact Sheet No. 104, available at www.who.int/mediacentre/factsheets/who104/en/print.html

[7] The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, p. 27

[8] Tuberculosis, Fact Sheet No. 104, available at www.who.int/mediacentre/factsheets/who104/en/print.html

[9] ibid.

[10] ibid.

[11] Stop TB: annual report 2001, Document WHO/CDS/STB/2002.17, WHO, Geneva, 2002, p. 1

[12] The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, p. 30

[13] The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, pp. 30-33

[14] For further information about TB-HIV co-infection, see The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, pp. 51-73

[15] The Global Partnership to Stop TB, slides from a WHO presentation.

[16] For further information about drug-resistant TB, see The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, pp. 74-87

[17] ibid, p. 76

[18] Tuberculosis, Fact Sheet No. 104, available at www.who.int/mediacentre/factsheets/who104/en/print.html

[19] The steps are: the vertical programme (1948-1963), integration of service delivery (1964-1976), integration of managerial functions (1977-1988), return to a specialised managerial approach (1989-1998), the resurgence of the integrated approach (1999-2000). See Raviglione, M.C., Pio, A., Evolution of WHO policies for tuberculosis control, 1948-2001, in The Lancet, vol. 359, no. 9308, 2 March 2002, pp. 775-780

[20] For the distinction between horizontal and vertical approach, see TB: towards a TB-free future, Document WHO/CDS/STB/2001.13, WHO, Geneva, 2001, p. 12

[21] For the distinction between specialised and integrated approach, see Raviglione, M.C., Pio, A., Evolution of WHO policies for tuberculosis control, 1948-2001, in The Lancet, vol. 359, no. 9308, 2 March 2002, pp. 775-780

[22] Tuberculosis control programme, WHA resolution, Document WHA44.8

[23] Raviglione, M.C., Pio, A., Evolution of WHO policies for tuberculosis control, 1948-2001, in The Lancet, vol. 359, no. 9308, 2 March 2002, pp. 775-780

[24] Tuberculosis control programme, WHA resolution, Document WHA44.8

[25] Global tuberculosis control: WHO Report 2001, Document WHO/CDS/TB/2001.287, WHO, Geneva, 2001

[26] The Global Partnership to Stop TB, slides from a WHO presentation.

[27] From a conversation with a member of the Stop TB Partnership Secretariat.

[28] Report of the ad hoc committee on the tuberculosis epidemic, London, 17-19 March 1998, Document WHO/TB/98.245, WHO, Geneva, 1998, p. 5

[29] ibid., p. 6

[30] For the definition of partnerships and their importance in the cooperation for health, see Part II, Ch. 3, p. 140

[31] The Global Partnership to Stop TB, slides from a WHO presentation.

[32] ibid.

[33] The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, p. 106

[34] From a conversation with a member of the Stop TB Partnership Secretariat.

[35] For further information about the Stop TB Partners' Forum, see Highlights: First Stop TB Partners' Forum, 22-23 October 2001, Washington, DC, WHO, 2001

[36] For further information about the Stop TB Coordinating Board, see Stop TB Coordinating Board, available at www.stoptb.org/stop.tb.initiative/default.asp

[37] For further information about the working groups, see The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, pp. 112-125, and Stop TB Working Groups, available at www.stoptb.org/Working_Groups/default.asp

[38] CDS, Global defence against the infectious disease threat, WHO, Geneva, 2002, pp. 141-142. Advance copy.

[39] For further information about the Secretariat, see The Secretariat of the Global Partnership to Stop TB, available at www.stoptb.org/stop.tb.initiative/default.asp

[40] From a conversation with a member of the Stop TB Partnership Secretariat.

[41] ibid.

[42] Amsterdam Declaration to Stop TB, available at www.stoptb.org

[43] ibid.

[44] ibid.

[45] Washington Commitment to Stop TB, 22-23 October 2001, Washington, DC, USA,

available at www.stoptb.org

[46] For further information, see www.stoptb.org/GPSTB/default.asp

[47] For further information, see www.stoptb.org/GDF/default.asp

[48] TB: towards a TB-free future, Document WHO/CDS/STB/2001.13, WHO, Geneva, 2001, p. 22

[49] CDS, Global defence against the infectious disease threat, WHO, Geneva, 2002, p. 144. Advance copy.

[50] For complete description of the four objectives, see The Global Plan to Stop Tuberculosis, Document WHO/CDS/STB/2001.16, WHO, Geneva, 2002, pp. 106-108

[51] From a conversation with a member of the Stop TB Partnership Secretariat.

[52] Global Drug Facility: securing access to high-quality drugs, Fact Sheet no. 1

[53] Global Drug Facility: securing access to high-quality drugs, Fact Sheet no. 1

[54] See www.stoptb.org/GDF/default.asp

[55] Millennium Development Goals, www.un.org/millenniumgoals

[56] ibid.

[57] Dr Jong Wook Lee, Director of the Stop TB Initiative and next Director-General, expresses his concern about TB: "future generations will no doubt ask us why we continued to allow two million people to die every year from a disease that can be cured with drugs that cost only US$ 10. They will rightly question our commitment, our priorities, our sense of justice, and our understanding of human rights. Global Drug Facility: securing access to high-quality drugs, Fact Sheet no. 1

[58] A corporate strategy for the WHO Secretariat, Report by the Director-General, Document EB105/3

[59] ibid.

[60] Proposed programme budget 2000-2001, available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=PPb2000e&softpage=Browse_Frame_Pg42

[61] Proposed programme budget 2002-2003 , available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=pb02-e&softpage=Browse_Frame_Pg42

[62] Proposed programme budget 2004-2005, available at

policy.who.int/cgi-bin/om_isapi.dll?infobase=PPB04e&softpage=Browse_Frame_Pg42

[63] See Part IV, Ch. 1, p. 216