PHA-Exchange> Notes on the "New WHO"

[Aviva]

Re: information regarding Dr Lee, the New WHO, the politics around the
GFATM and access to drugs.

What does the ‘New WHO’ look like?

Most striking feature of the new direction is, first, the emphasis on
what country needs and what governments want.  Dr Lee believes in the 
sovereignty of nations and is not a ‘globalizer’.

This assessment was confirmed in Dr Lee’s speech this morning (July 21,
2003). Basically, he stressed his orientation as “listening to what
countries have to say”, listening to country needs, and placing
emphasis on human resources.
“Listening to the people” as some will recall, was the leitmotiv of Dr
Mocumbi, from whom Lee is taking a number of cues, including the strong
emphasis on Alma Ata.

At his press conference last week in Paris, Dr Mario Raviglione- who is
now acting director of Stop TB, (replacing Dr Lee who had that post
before his election) said two things about what he called the “new
WHO”: emphasis will be placed on primary health care, and on bringing
together, for the first time, TB, HIV and Malaria.

This brings TB back up on the WHO agenda and which places
emphasis on TBHIV. This was stressed privately during the meeting of
the TBHIV Working Group (StopTB-WHO) meeting last month in Montreux,
Switzerland.

It would seem that the idea of the HTM (HIV-TB-Malaria) -cluster is a
way for WHO to get back  to the Global Fund on AIDS, TB Malaria (GFATM); at 
the“Fund the Fund”  select meeting in Paris last week, (Feb 16) Dr Lee
was only one speaker among others, even stuck at the tail end of the
day, which means WHO is not considered priority by the GFATM, it’s
still a one way street (WHO is trying to get close to the GFATM but the GFATM
people are not so sure about WHO)

The new orientation of WHO is not so  much vis a vis the Fund as to give 
technical expertise to  countries on the three diseases.
Dr Lee is positioning WHO very very strongly as assisting governments get their 
say and get funding on the international scene.

Dr Lee is also recruiting Dr Macumbi’s  supporters in the last
election for new DG: the Brazilians. Therefore P. Teixeira of the Brazil HIV
program is now replacing Swartzlander as head of the HIV department.

This is a message to the developing countries who want to walk in the
footsteps of Brazil as far as treating their people with antiretroviral
treatment ART.

During the TBHIV working group meeting, José Perriens, who now has left 
UNAIDS for WHO, presented the WHO report on ART in resource poor settings, 
and said that WHO was considering the setting up of a Global Drug Procurement 
Fund for ARV, along the lines of the Global TB Drug facilities. This program is 
now in full swing with the participation of MSF (Doctors without Borders).
What is clear is that the “New WHO” is going to put all efforts into
the “3 by 5” plan, three million people on ARV by 2005.
And, to be noted, this  may not be US Administration priority as they
balk at funding the Fund.
Romano Prodi of the EU insisted on meeting the pledge of the 1 billion
for the GFATM at the closing of the IAS which was all on access to ARV.

Regarding the importance of putting HIV together with TB and Malaria
Speaking to the press in the hallways of the GFATM meeting In Paris
(July 16), Jeffrey Sachs developed an argument for dealing with the
three diseases together:  “HIV is worsening malaria everywhere.. but
also malaria is worsening the spread of the HIV epidemic by increasing
the viral load”… Later on, Sachs added that the same was true of
tuberculosis.

The person co infected with TB and HIV would produce much larger
quantities of HIV virus than the person not infected with the TB
bacilli, (up to 160 times more HIV in viral load measurements) which
meant very simply that a country with a large TB epidemic would have an
environment propitious to a fast spread of HIV, as transmission of HIV
(whether mother to child, sexual, or through dirty needles) is
dependent on viral load.
Once somebody was TBHIV infected, the TB disease would be worse, AIDS
would be worse, transmission of HIV to others would be facilitated.
The same synergy worked, Fauci showed, for parasitic diseases.
In 1996, Fauci said that “If we were serious about stopping the spread
of HIV in Africa we would launch a massive effort to deal with
prevalent bacterial and parasitic diseases.
 The synergy between HIV and intestinal parasites has likewise been proven but 
is not often spoken of.

Today, the creation of the GFATM and the new “HTM” (HIVTBMalaria)
cluster at WHO, shows the intention to deal with the three diseases in
parallel. It is also in big pharma’s interest to have more attention on
TB, and the World Bank is going ahead with a mix of TB drugs and ARV
today.
But, as far as can be heard and seen, the Big Three programs are still
separate and unchanged, they are just “glued” together with scotch
tape.

As regards the ARV (antiretroviral) and ATD (anti-TB drugs) push there
are two different trends: one, associated with UNAIDS, WHO for the past
year, MSF, Harvard, says that ARV can be dispensed in resource poor
settings WITHOUT using an overtaxed and overburdened health system.
This approach is favored by the World Bank which does not want to invest in
building up infrastructure or human resources, or event to modify
course (along with IMF) from Structural adjustment renamed PRSP.
There are ideas of franchising both ARV and TB drugs and experiments in
that regard. It means that a lay person can take on a franchise from a corporation 
(could be an NGO, probably an example of a public private partnership) handling 
drug procurement.
It also means – and there was a debate between African medical leaders
and Perriens on that score at the TBHIV Working Group meeting- that WHO
UNAIDS are arguing for having nurses or even lower level health care
workers dispense ARV and also do the testing for HIV, reading of tests,
or some CD4 count etc, without technical expertise but with just
minimal training. This idea was strongly opposed by African physicians
attending the TBHIV mtg in Montreux.
This in a situation in which only 7% of the African population has
access to VCT (voluntary Counselling and Testing)- (according to
WHO-Afro rep speaking in Montreux meeting). How are ARV to be dispensed
if people don’t know they are HIV+ and the resources for testing don’t
even exist?

One constant complained in Montreux by African participants, was the
lack of medical personnel to even handle TB, especially with the
increased TB load (up to a 10 fold increase in cases in recent years
for all the high HIV burden countries of Africa).

Elizabeth Madraa, head of the HIV program in Uganda, who attended that
TBHIV meeting in Montreux, pointed out that the big problem in handling
TB HIV today was the massive exodus of medical personnel, and that this
exodus increased as the AIDS wave increased (with 80% of hospital beds
occupied with HIV+ patients in many countries, a figure from Montreux).
One participant from Malawi pointed out that while the shortages of
nurses is becoming more severe every month, the schools for training
nurses have in part closed, which means the training capacity no longer
exist because they have been closed.


When Dr Lee speaks of Alma Ata and of the emphasis on
Primary Health Care it is not yet definite what he means. 1) It could
be lip service to fashion and the NGOs. 2) It could be for real, and
certainly that would mean the emphasis would shift from bet nets to
water management, it’s a possibility, as water management was mentioned
in the speech. Or 3) it means more of the World Bank’s so called pro
poor approach.

It’s probably a mix of the three. Insiders at WHO (high level) consider
Lee as “pragmatic” as Brundtland as far as links with industry go, and
certainly, his management of the “Public Private Partnership” which
Stop TB is, would indicate that, on the other hand he would be less WTO
oriented, and, through leaning on the Europeans-Brazilian axis, would
try to go for a compromise and more of a country focus.
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