A WHO staff member's parting salvo to the international health agency and its neoliberal approach to health Sam Burcher

Social scientist, Alison Katz has left the World Health Organisation (WHO) after 17 years of devoted service, condemning its “Let us live and let them die” attitude, which sums up the neglect of millions of people over the past three decades, suffering and dying from diseases of poverty, including notably HIV/AIDS [1]. She is the second AIDS researcher to leave within the past 12 months (see On Quitting HIV [2]).

“For over twenty years now, the international AIDS community has persisted in a reductionist obsession with individual behaviour and an implicit acceptance of a deeply flawed and essentially racist theory.” Katz writes. She believes that the narrow and totalitarian approach to AIDS by the WHO not only has had negligible effect, but also has betrayed public health principles and perversely forbidden exploration of any alternative perspectives. Like many others, Katz questions the exclusion of a plethora of co-factors known to increase biological susceptibility to infection by all disease agents, including HIV, among which are under-nutrition, poverty, powerlessness, and the basic necessities for a healthy and dignified life.

She believes that the WHO has fallen victim to neoliberal globalisation, and by default, to the economic interests of powerful nations and the transnational corporations. In an open letter dated January 2007 [3] addressed to Dr. Margaret Chan, the incoming Director-General of WHO, Katz set out seven key points to steer her focus back to serving the public, including the critical importance of addressing the commercialisation of science, and the close relationship between industry and academia as highlighted in Institute of Science in Society's discussion paper Towards a Convention on Knowledge [4].

The neoliberal approach to health

There is a strong tendency in the neoliberal approach to health – and particularly in relation to HIV/AIDS, to blame victims, Katz says [5], for their faulty or irresponsible behaviour. Demeaning stereotypes, coupled with flawed analysis, and ineffectual policies do not appear to have contributed to any significant decrease in infection rates in the worst affected regions such as the continent of Africa. Furthermore, the world's first global sex survey published in The Lancet in 2006 found that multiple sex partners were more common in industrialized countries where disease incidence is relatively low [6]. According to Katz, the dominant neoliberal perspective reinforces the structures of hegemony that create poverty and powerlessness which are themselves the root causes of avoidable disease and death. (Poverty eradication must be central to change and the narrow focus to the problem is being challenged by women in Africa (see Women Confront Aids in Africa SIS 34 [7]).

Eileen Stillwaggon, an associate Professor of Economics at Gettysburg College USA, says that [8] the ecology of poverty must be understood, as populations that lack access to medical care and are already coping with parasitic and multiple other infections, are more vulnerable to other diseases, regardless of how they are transmitted. In this respect, HIV/AIDS is no exception. The public health principle, neatly summarized by Pasteur as “the bacteria is nothing; the terrain is all”, applies to all the diseases of poverty. The focus on individual sexual behaviour is itself highly stigmatising - in addition to being unscientific. On an optimistic note, Stillwaggon observes that solutions to the problems caused by almost all the co-factors exist, and institutions, like the WHO are well placed to advocate for them among vulnerable populations. ISIS has proposed many affordable and patent-free alternative treatments to the disease and its' co-factors in Unraveling AIDS [9]).

In order to neutralise the entrenched neoliberal bias within international agencies Katz believes that the WHO must return to its founding principles and advocate for attention to root causes – the social and economic determinants of health and disease. In today's world, this implies denouncing unfair rules of trade and commerce, the exploitation of national resources, and ruthless liberalization foisted on developing countries, all of which have been shown to have devastating effects on the health of populations. Furthermore, the WHO must take the lead in providing scientific research with independent scientists free of vested interests. To achieve its mandate of “Health For All”, the WHO must support serious science based on sound evidence. Millions of people's lives are at stake.

Political prejudice within the WHO

Katz worked for 12 years in the division of WHO dealing with family, community, sexual and reproductive health, and 8 years in the HIV/AIDS department. In 1999 she responded to an Internet discussion posting from the perspective of biological vulnerability to HIV infection and racist assumptions underlying current policies and strategies. Her supervisor, on instructions from the executive director, immediately censored her by sending an email instructing that she must not debate this issue. At the same time she received a request from the editor of the African Journal of Aids Research to write up her ideas in an article [1]. Shortly after that, she was isolated from all technical work within her department for 18 months.

Following her isolation, Katz's contract was not renewed, so she submitted an internal legal appeal against the WHO for reinstatement and for a proper contract after serving 11 years on 37 temporary contracts. She won the appeal on condition that she leave the HIV/AIDS department. As a working mum supporting three children, she had no choice but to accept the Director General's offer.

Efforts on Katz's part to discuss alternative approaches with the WHO HIV/AIDS programme director and the UNAIDS executive director have consistently been declined, even after the publication of the Lancet series, mentioned above, which supports the perspective she is advocating.

Independence of international civil servants to fulfil WHO's mandate

Katz's concerns expanded to the question of independence of international civil servants, which is seriously undermined by neoliberal influence exerted through powerful member states, private sources and extra-budgetary funding. Pressures at this level have resulted in a repressive, authoritarian and hierarchical management style, which discourages free debate. Katz joined the staff association to fight for proper contracts for all long term “temporary staff” - some 55 percent of the workforce. The success of this action was limited. A very small proportion of “false temps” were regularized into proper contracts and then through a major, costly “restructuring” exercise, many of these long serving staff then lost their jobs, often to inappropriately qualified appointees with better connections.

These struggles took place against what she describes as a background of nepotism, cronyism, corruption, harassment, financial mismanagement and chaotic, highly discretionary, human resources management [5]. Furthermore there is an under representation of Africans, Asians, Latin Americans, or Eastern Europeans within staff departments. The predominant influence of the UK, USA and Canada, as well as Australia, and New Zealand; whose representatives are invariably white, male, Anglo-Saxon Protestants linked by powerful networks prevails.

WHO's first strike and out

Together with a small group in the staff association, Katz organized a one hour work stoppage, the first industrial action in WHO's history, in which 700 staff participated. Her post was abolished three weeks after the work stoppage and three weeks before the normal renewal of her 2-year contract. Swiss unions and staff association lawyers qualify this as interference in the right of association; the WHO administration qualifies it as a “coincidence”.

Katz believes that the WHO must respect international labour standards, including negotiation status for the staff association, in line with ILO (International Labour Organisation) covenants; to provide workers with formal power, adequate funding, and strong links to a bona fide UN umbrella union. WHO staff should be held accountable to WHO's 1978 constitutional mandate, to the Alma Ata principles underlying Health for All, and to the UN Charter and should fully understand the duties and responsibilities of public service.

WHO's challenge to achieve Health for All

Katz calls for a return to a basic needs and rights-based approach to health [1] in order to provide a sustainable and meaningful response to AIDS that is simultaneously a response to all the diseases of poverty. An alternative political strategy for AIDS and its co-factors would embrace macroeconomic reforms for a fair, rational and sustainable international economic order so that democratically elected governments may reasonably meet people's basic needs, including health, without external interference.

In her open letter [3], Katz urges WHO's newly elected Director General, Dr Chan, to address the following major issues in order to fulfil her vision. A focus on inequality rather than poverty; holding meetings and consulting with the poor rather then the rich; a solid, equitable tax base, nationally and internationally, rather than public-private partnerships; knowledge for the public good rather than corporate “science”; respect for ethical values and an appropriate balance between loyalty to WHO's constitutional mandate and loyalty to current governments of powerful member states and current office holders.

Article also published in International Journal of Health Services 2007DOI:10.2190/HS.37.4.l

References

1.        Katz A. AIDS, individual behaviour and the remaining unexplained variation. African Journal of   AIDS Research, 2002, 1: 125-142.
2.        Ho. M.W. On quitting HIV. Science in Society 2007 34.
3.       Open letter to Dr Margaret Chan http://www.phmovement.org/files/alison_letter.pdf
4.       Ho MW. Novotny E, Webber P, Daniels EE, et al.2002 Towards a convention on knowledge. ISIS-SGR-INES-TWN-Tebtebba discussion paper. © Institute of Science in Society.
5.       Katz A. The independence of international civil servants during the neoliberal decades: Implication of the work stoppage involving 700 staff of the World Health Organisation in November 2005. Unpublished paper.
6.       Global sex survey: Marrieds do it more than teens. FoxNews.com October 31, 2006. http://www.foxnews.com/story/0,2933,226560,00.html?sPage=fnc.health/sexualhealth
7.      Burcher S. Women Confront Aids in Africa. Science in Society 2007 34.
8.      Stillwaggon E. 2005 The Ecology of Poverty: nutrition, poverty and vulnerability to HIV/AIDS 9, 167-172 Oxford University Press, ISBN-10: 0195169271 http://www.ifpri.org/pubs/books/oc50/oc50ch09.pdf
9.      Ho MW. Burcher S. Gala R. Veljkovic V. Unraveling Aids: The independent science and the promising alternative therapies 2005 Vital Health Publishing ISBN 1-890612-47-2