Yaws

PAUL DIETRICH WAS visiting Mozambique's capital city, Maputo, during its civil war in 1984, when an educational billboard taught him a lesson he never forgot.

Dietrich, a former publisher of the old weekly Saturday Review, was in Africa working with a Catholic charity. He was driving in his Land Rover, the only working motorized vehicle for miles. Poverty-stricken people surrounded him, most of them on foot, though a lucky few rode oxen. The billboard was the only one he'd seen in all Mozambique. Though most of the chaotic, war-torn country was plagued by regular power outages, the sign had its own electrical supply. This billboard was paid for by the World Health Organization (WHO), the international bureaucracy created, in the words of its constitution, to "promote and protect the health of all peoples."

It urged the people of Mozambique to remember to buckle their seatbelts.

It also helped cement Dietrich's doubts about WHO'S vision and mission. After seeing that billboard, and contemplating what it said about WHO'S priorities and goals, he became one of WHO'S most vocal critics. In the early 1990S, Dietrich served on the development committee of the Pan American Health Organization (which functions as an American branch office for WHO). He has also been president of the Institute for International Health and Development. Dietrich wrote about WHO frequently for The Wall Street Journal, and provided material for exposes of WHO shenanigans on 60 Minutes and various TV documentaries in Europe (where WHO'S activities are minded far more closely than in the United States, even though the U.S. provides 22 percent of the organization's regular budget).

Dietrich publicly and repeatedly complained that WHO was a bureaucracy for bureaucracy's sake, mired in useless statement-making and conference-giving. He thought it focused too much on First World concerns--such as seatbelt campaigns and smoking--and not enough on the developing world's sick and poor.

For his troubles, Dietrich became the target of a WHO-sponsored investigator who dug into his and his wife's background, finances, and politics. Dietrich only learned of the investigation when a mole in WHO'S Geneva headquarters faxed him a copy of the final report. WHO singled out Dietrich, now an investment banker, in an August 2000 report that received heavy play in the New York Times and Washington Post. The report, dedicated to the tobacco industry, claimed Dietrich's motives were purely mercenary. He was named as a paid agent in a sinister international tobacco industry scheme to discredit WHO. The truth, Dietrich tells me, is far less sexy: A law firm he had worked for did work for tobacco companies, along with almost every other Fortune 500 company.

To WHO, which claims to be devoted to science in the name of public health, Dietrich's observations and conclusions should be nullified by its ad bominem assault. Dietrich's primary complaint, though, will resonate with anyone who assumes that an international health organization's resources should be primarily aimed at the direct control and eradication of infectious diseases, rather than at behavior modification programs concerned with such matters as seatbelts and smoking.

But WHO's agenda is more ambitious than merely bringing medical care to the world's disadvantaged. Health, in a definition the group adopted over 20 years ago, is "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." That is a totalist vision, and an alarming one. Armed with a bureaucrat's mentality, an arsenal of questionable data and conclusions, and a billion dollars in taxpayer money donated by governments around the world, WHO's goal seems not so much to bring the world "health" as a physical condition as it is to bring the world under the control of the international mavens of "public health," the sociopolitical discipline.

But WHO is more an organization fighting for its life than one fighting for real power. As curable infectious diseases become a less significant factor in world mortality rates, WHO's budget has stagnated at around $1 billion a year for nearly a decade now. Various other huge bureaucracies-such as the U.S. Centers for Disease Control and the World Bank, whose budget on international health matters is slightly higher than WHO's--have poached on its turf.

Why, to borrow Paul Dietrich's question, is WHO concerned with seatbelts and smoking when the world's poor are still dying of measles and tuberculosis? Public choice analysis--which presumes that government agencies, like their private-sector counterparts, seek to grow their market share--suggests an answer: Since the WHO's funding is mostly from First World governments, making them its relevant "customer base," it caters to First World concerns. WHO's recent history has been a vivid example of bureaucratic mission creep. In expanding its purview far beyond the merely medical, WHO is trying to stave off extinction.

Amazing Journey

War, the radical journalist Randolph Bourne wrote, is the health of the state. Bourne meant that war creates a sense of crisis and embattlement, making citizens ready to cede their liberty to gain a sense of security.

But governments continually seek new excuses to expand their authority. Nearly a century after Bourne wrote his famous words, risk protection has become a central mission for governmental bodies. As Sheldon Richman, editor of the libertarian journal Ideas on Liberty, has put it, health is now the health of the state. Richman's observation deserves to be carved in marble in the plush Geneva offices of WHO.

WHO was founded in the wake of World War II, in a wave of optimism over the ability of international bureaucracies to create and direct a safe and sane world. With its mission concentrated on managing or eradicating infectious diseases worldwide, the group had some notable successes and some near-successes. It helped coordinate the international effort to eliminate smallpox, officially vanquished as of 1977. A WHO document uses clotted official prose to describe the group's role in the smallpox baffle. WHO says its contribution was in "its energy and prestige as a catalyser of global efforts bringing together scientists, governments, health workers, and ordinary citizens," and that "technical difficulties...were overcome through prompt WHO-coordinated research." The group also stressed the importance of "its neutrality and independence of national rivalries and suspicions."

WHO also played a major coordinating role in controlling yaws in the late 1940s and onchocerciasis ("river blindness"), leprosy, and polio in the past three decades. A WHO-organized Malaria Eradication Program in the '60s made substantial progress in stemming that disease. As late as 1964, WHO publications expressed optimism that malaria would be wiped out. Alas, malaria resisted eradication and the disease still kills over 1 million people a year. (The demonization of the U.S.-banned pesticide DDT, the cheapest and most efficient tool for killing the mosquitoes that spread the disease, bears a large part of the blame for the continued death toll.)

WHO'S main success story remains its role in eradicating smallpox. Sometimes, though, it seems to believe the world will be impressed with the sort of thing that really occupies it these days. One WHO propaganda book lists five things we'd be missing in "A World Without WHO"-- presumably what it considers its most important achievements. None of them had to do with curing a single disease in a single person. Instead, they aver that in "a world without WHO...national health officials would not be able to count on global moral support in their battle against tobacco addiction," and "there would be no unifying moral and technical force to galvanize, guide and support countries in achieving health for all by the year 2000."

By the end of the 1970s, WHO's official rhetoric about its core purpose began to shift from simple disease eradication. In 1978, at a joint meeting of WHO and UNICEF in Kazakhstan, in the former Soviet Union, WHO adopted "World Health for All by 2000" as its goal. This conclave of international bureaucrats vowed that, by the close of the 20th century, "All governments will have assumed overall responsibility for the health of their people...through influencing lifestyles and controlling the physical and psychosocial environment." An "equitable distribution of health reserves, both among countries and within countries...is therefore fundamental to the strategy." This plan was "part of that fundamental reorganization of human relationships in the world through the search for a New International Economic Order."

Meet the New Boss

By the mid-1990s, WHO was mired in what the British Medical Journal called "a morass of petty corruption and ineffective bureaucracy." Under Director General Hiroshi Nakajima, a Japanese pharmacologist, WHO was so widely understood to be mired in cronyism and financial irregularities that such longtime boosters as Denmark and Sweden slashed their contributions; even the group's official auditor resigned in disgust. Nakajima's prominent position was important to Japanese self-esteem, so Japan embarked on a campaign in 1993 to make sure he was re-elected to a second five-year term. Among other gambits, the Maldives and Jamaica were warned that Japan would stop importing anything from them if Nakajima didn't get their vote.

Nakajima got his second term, but in 1998, with WHO morale and reputation at an all-time low, he was replaced by Gro Harlem Brundtland. With a masters in public health, Brundtland had spent most of her career as a politician, serving three terms as prime minister of Norway. She had also founded and led the UN's World Commission on Environment and Development. As WHO's new head, she promptly announced such vital-to-health goals as ensuring that six of every 10 new hires would be women.

In a world still fighting infectious disease, Brundtland's WHO has issued statements, studies, and reports on such topics as blood clots in people who sit still on airplanes too long, helping people remain active while aging, the hazards of using cell phones while driving, the importance of debt relief for poor countries, how tobacco is "a major obstacle to children's rights," and rates of alcohol abuse among European teens. The Lancet, the respected British medical journal, summed up her priorities thusly: "Brundtland has so far set out a conspicuously political agenda: her targets are poverty, underdevelopment, and social inequality."

To her credit, she has tried to reduce the amount of money spent at WHO's posh headquarters. She has succeeded in lowering her own annual office expenses by $4 million over the next two fiscal years. She has also moved malaria control back near the top of the group's agenda.

Not to her credit, she has continued WHO's turn from combating disease in its traditional--and curable--definition of infectious biological entities to an agenda of social control meant to stop people from indulging in freely chosen, if risky, pleasures.

Hence, when Brundtland launched two "cabinet-level" priorities, one was a "Tobacco-Free Initiative" that now costs $14 million a year. (Malaria control is the other.) What does WHO expect to accomplish in aiming its resources and rhetoric at tobacco smoking? In characteristically vague WHO language, the initiative is meant to "galvanize global support for evidence-based tobacco control policies;' to "accelerate...strategic planning," and to "integrate tobacco into the broader agenda."

More specifically, the initiative's goal is to browbeat member nations into banning cigarette advertising and massively increasing cigarette taxes (never mind that such a policy may lead to black markets and attendant criminality). Backing WHO on this are several major pharmaceutical companies that have traditionally been enemies of the organization, which has long criticized what it considered the companies' brutal hegemony over poor nations. The pharmaceutical companies are thrilled that an international agreement might create an enforced market for non-smoking nicotine delivery devices, allowing drug makers to rip a chunk of the nicotine market from the grip of the tobacco barons.

In its war on tobacco, WHO has attempted Orwellian moves of almost absurd incompetence. In 1998, forinstance, the group was supposed to release an enormous 10-year study on second-hand smoke's links with lung cancer, the largest ever done in Europe. A small mention of it was printed in a WHO report before the whole study was available. The British Sunday Telegraph tried to get a copy of the study, since the brief reference intriguingly implied that it could not find a statistically significant link between second-hand smoke exposure and lung cancer. The Telegraph implied that WHO was trying to bury the report since its results went against their official anti-tobacco stance.

WHO and other anti-tobacco groups were outraged. One group, Action on Smoking and Health, filed an official complaint with Britain's Press Complaints Commission over the supposedly erroneous reporting. (The commission found in the Telegraph's favor.) WHO responded to reports that its study did not find a statistically significant link between second-hand smoke and lung cancer in a press release headlined, "Passive Smoking Does Cause Lung Cancer, Do Not Let Them Fool You"--strange, strained language from a supposedly scientific organization.

Underneath that colorful headline, the press release states, in italics, that "passive smoking causes lung cancer in non-smokers." Then, in the very next paragraph, it clarifies, "The study found that there was an estimated 16% increased risk of lung cancer among non-smoking spouses of smokers. For workplace exposure the estimated increase in risk was 17%. However, due to small sample size, neither increased risk was statistically significant." In other words, the Telegraph report was exactly correct: The study had found no statistically significant link between secondhand smoke and cancer.

As for the "suppressed" part, WHO insisted that the paper was merely being peer-reviewed, not hidden. Yet three years later, you'll still find no mention of the report on WHO's list of "Comprehensive Reports on Passive Smoking by Authoritative Scientific Bodies."

Is WHO a Bargain?

Treating the behavior of tobacco smoking as a "disease" that must be eradicated by international bureaucrats is bizarre enough. But WHO'S full agenda of social control is even more starkly evident in documents surrounding one of their biggest research projects of the 1990s. The project was done in collaboration with the Harvard School of Public Health. (WHO is almost never the sole element in any of its programs.) It was a study on the "Global Burden of Disease and Injury," an attempt to calculate out to the year 2020 what will be the major causes of ill health and death all over the world.

The document is essentially an extended cri de coeur to the world not to let WHO fade away, even as infectious diseases shrink in global significance. (Strangely, WHO has never been a leader in the fight against AIDS, the most-discussed infectious disease of the past 20 years; the group has been relegated to simply one bureaucratic partner, along with the World Bank, UNICEF, and others, in the umbrella program UNAIDS.)

As a result of its embattled position, WHO has a skewed vision of medical progress. Most observers see the shift in leading causes of death--from communicable diseases such as smallpox and measles to non communicable ones such as heart disease and cancer--as a sign of success. If everyone has to die, better that it should come from being too fat or too old. The shift from communicable to noncommunicable diseases as causes of death reflects general increases in wealth and lifespan. But for WHO, such progress is life-threatening to its own organization.

In the "Global Burden" summary document, WHO admits that its entire IO-volume edifice of quantification is built on a foundation of sand. It claims to be calculating what will end the most lives worldwide by 2020. it admits, "In many countries, even the most basic data--the number of deaths from particular causes each year--are not available." Further, "estimates of numbers killed or affected by particular conditions or diseases may be exaggerated beyond their demographically plausible limits by well-intentioned epidemiologists who also find themselves acting as advocates for the affected populations in competition for scarce resources. If the currently available epidemiological estimates for all conditions were right, some people in a given age group or region would have to die twice over to account for all the deaths that are claimed."

The study relied on a bit of numerical chicanery, originally developed by the World Bank: the "disability adjusted life year" (DALY). is a complicated bit of scientism designed to quantify the effects of illnesses in terms of years of life lost. The DALY is based on the principle that a year living with certain conditions isn't really like a year of living. It allows WHO to make a big deal about "unipolar major depression," which it predicts will be the number two cause of "disease burden" by 2020, even though the ailment is not known to kill many people.

DALY is not objectively veriflable--WHO came up with its numbers by asking a bunch of health workers how much they thought certain ailments reduced the value of a year of their life. So now science has demonstrated that below-the-knee amputation is somewhere from 0.22 to 0.36 "severity weights" more terrible than vitiligo (the "whitening" disease famously suffered by Michael Jackson) on your face. A small group of people's raw opinions were transformed through WHO's alchemy into hard public-health science.

It is only through the DALY that WHO can weigh mental illnesses as high on their global burden of disease as they do. Emphasizing such illnesses--WHO claims that 16 percent of "years lost to disability" in sub-Saharan Africa are due to mental illness--fits in well with the group's totalist agenda. After all, treating such illnesses often requires doing things to the "patient" against his will. At a point in history when its rationale is thankfully diminishing, WHO is maniacally reinventing itself as the agency that might solve every problem that hurts or disables anyone. (They emphasize traffic accidents and injuries in this report, though it is uncertain what a health authority can do to stop them.) The shoddy numbers and tendentious definitions-smoking, drinking, and sex are all classified as "risk factors for disability or death," a rhetorical trick to disarm anyone who would defend someone's right to indulge in them--enable an agenda of massive social control.

Let's See Action

When reading WHO'S reports, press releases, and other documents, one struggles to find non-abstract nouns and verbs representing actions a human being might need a body to perform. While infectious diseases are thankfully becoming a less significant cause of death globally, they do still kill at least 3 million children every year, so one might expect WHO's rhetoric to be dominated by talk of inoculation and cure. Instead, one overwhelmingly finds talk of forming coalitions to manage and monitor systems that lay the groundwork for plans to coordinate actions to develop the knowledge and skills necessary to begin the process of forming coalitions, repeat as necessary.

WHO's 2000 annual report was dedicated not to improving health, but to improving health systems--a permanent task for bureaucracies. "Ultimate responsibility for the performance of a country's health system lies with government. The careful and responsible management of the well being of the population...is the very essence of good government. The health of people is always a national priority: government responsibility for it is continuous and permanent," Director General Brundtland wrote in her introduction. This emphasis fits perfectly with WHO's love of the bureaucratic and managerial, as opposed to the medical and action-oriented. (Unsurprisingly, WHO ignores the findings of health economists that health care systems qua health care systems don't appear to account for more than a handful of the years of additional lifespan that human beings have gained on average in the past century.) Given the group's agenda, it's no shock that the portion of WHO's budget dedicated to communicable disease prevention, e radication, and control is set to fall by $30 million over the next two fiscal years.

To WHO, health systems are more important than health outcomes. Its rhetoric sometimes acknowledges this, as in a WHO document that avers its activities are aimed to "strengthen the health sector at a country level." And the health of WHO's own system might be the most important thing of all. An analysis of WHO's 1994-95 budget, done by economists Richard Wagner and Robert Tollison, found that WHO spending on meetings and its executive board equaled its spending on immunizations, tuberculosis, and diarrheal diseases combined. (A more recent analysis of spending on bureaucracy vs. programs would be harder to do, since WHO's official budget figures are now broken down only in terms of countries and disease clusters, not what the money is actually spent on. Given that, there's no way to know whether money is spent on, say, a conference dedicated to discussing a disease or actually going into the field to treat it.)

WHO's obsession with system over result can also be seen in the fact that, although the U.S. populace is in most respects healthier than that of Third World countries that try to centrally manage health care, WHO wants to eliminate fee-for-service medicine entirely.

If anything, WHO seems proud of the excessively bureaucratic nature of its work. It issues press releases celebrating its role as middleman between a pharmaceutical company donating needed drugs and the organization Doctors Without Borders, which actually goes into the field to administer them. WHO is an organization by and for bureaucrats and health ministers--for whom it provides jobs, fellowships, and chances to go to conferences in exotic vacation spots--not the world's sick. At its worst, it is an active proselytizer for aiming national and international health resources at things irrelevant to actually fighting disease. If the world wants a transnational organization funded from tax dollars to propagandize and nag us about our chosen behaviors, let them try to sell such a proposition openly.

WHO officials defend themselves against accusations of uselessness by stressing that healing the sick isn't really what they are all about. "We're a scientific agency," Dr. Anthony Piel, a former chief advisor to WHO's director general, told a British television reporter. Asked why they keep their headquarters in cushy, elegant, and quite healthy Geneva, Piel said, "We have looked into moving the WHO to other poorer countries... where the cost would be lower.... But the last time we studied that we considered, for example, Yugoslavia, we considered Lebanon, Jordan, Tanzania, and Rwanda...." WHO seems to have a hard time thinking of any cheap place closer to real health problems that isn't a war zone.

WHO's flaws and misdirected ideology, however sinister their potential implications, are more a matter of bureaucratic turf-building and feather-bedding than a fiendishly executed world control agenda. Faced with the reality that as a science and research organization they are more of a clearinghouse; that as an international researcher and advisor on health matters they often take second place to the World Bank (WHO's own reports are far more likely to cite substantive research done by the World Bank than any of its own original work, of which there is very little); and that in their First World-oriented agenda they are merely another bureaucratic layer echoing already existing national health ministries and the initiatives of other non-governmental organizations and international bureaucracies, WHO is scrambling frantically for its life. But it needn't worry too much. Bureaucracies, once created, almost never leave the stage, as their own will to live energizes them to a degree that surpasses their opponen ts' interest in eliminating them.

Nothing condemns WHO's current agenda more than some of its own pronouncements. In a 1999 press release, WHO declared that six illnesses accounted for 90 percent of all infectious disease deaths among people under 44 years old: malaria, tuberculosis, measles, diarrheal diseases, acute respiratory infections (including pneumonia), and AIDS. The same press release declared that "the tools to prevent deaths from each of these six diseases now cost under $20 per person at risk, and in most cases under $0.35. Yet these diseases still caused over 11 million deaths in 1998."

Leaving aside the questionable belief that existing AIDS therapies, still mired in uncertainty, are reliable "tools to prevent death," we have WHO declaring that 11 million deaths--90 percent of all infectious disease deaths for people under 44 years old--could have been easily prevented with an expenditure of, at its lowest, $3.9 million, and at its highest, $220 million. That is, anywhere from 0.4 percent to 20 percent of WHO's budget for one year.

Wagner and Tollison's analysis of WHO's budget in the mid-'90s found the group's spending heavily weighted toward conferences and headquarters expenses and away from actual on-the-ground aid in disease-fighting. They noted 70 percent of the budget then went to administrative overhead and the Geneva headquarters. In 1995, Tollison observed on British TV that "the World Health Organization is famous for its conferences, but I think that any ordinary person complying with a decision to spend on those conferences or to spend on senior executives in Geneva versus looking at real public health problems in the field, where little children are dying for want of a shot, I don't think anybody would make any other decision than to say, get the resources out of Geneva, quit having the conferences. Inoculate those children."

But as Paul Dietrich first began to realize over 15 years ago in the hot Mozambique sun, buckle-up billboards--along with phantom studies on second-hand smoke and warnings about driving while talking on cell phones--are higher priorities to the public-health mandarins in Geneva. In pursuit of perpetual bureaucratic life, WHO has changed its mission from eradicating disease to a lunatic bid for never-ending social control. In a strange way, in extending its own life, WHO has rendered itself moribund.

Brian Doberty is an associate editor of reason. Some of the research for this story was done under the auspices of the Warren Brookes Fellowship at the Competitive Enterprise Institute.

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