't Hoen

Barraclough

Ellen 't Hoen

Rowan Gillies

The Lancet

Tido von Schoen-Angerer

Williams

English

Gillies, R

von Schoen-Angerer, T

't Hoen, E

MSF Field Research

www.thelancet.com   Vol 368   October 21, 2006  1405
Historic opportunity for WHO to re-assert leadership
When  countries  gather  for  WHO’s  Executive  Board 
meeting  next  month,  to  appoint  a  new  Director-
General, they must select a candidate with the courage 
and political leadership necessary to address the most 
critical challenges the UN agency is facing today.
The  recent  appearance of  extensively drug-resistant 
tuberculosis illustrates the scale of the work ahead.
1 The 
health threat posed by this microbe in settings with a 
high prevalence of HIV highlights the urgent need for 
action for WHO to set the agenda for the fast-tracked 
development of new drugs and better and easier-to-use 
tests to diagnose tuberculosis and detect drug resistance, 
to replace today’s increasingly ineﬀ  ective tools.
WHO will need to lead a process involving health min-
istries,  regulatory  agencies, drug  companies,  product-
development  partnerships,  funding  bodies,  and 
non-govern mental  organisations,  and  it  will  need  to 
deliver.
HIV/AIDS is another immediate issue. With the end of 
the 3 by 5 programme, WHO today lacks any strategic 
plan for the coming years, despite ambitiously calling 
for  universal  access  to  AIDS  treatment.
2  Now  that 
newer compounds are increasingly needed to deal with 
resistance, the cost of treating AIDS is set to skyrocket.
3 
How does the agency plan to respond?
Research  and  development  needs  are  also  pressing 
in AIDS. These needs include the development of new 
ﬁ  xed-dose  combinations  of  second-line  drugs  and 
formulations  for  children,  and  simpler  ﬁ  eld-adapted 
diagnostics.  Drugs  in  research  must  be  speciﬁ  cally 
developed  to  answer  the  needs  of  resource-poor 
settings—and not only cater for populations of patients 
in rich countries.
On a programme level, WHO will need to address more 
forcefully the crying need for greater human resources 
in  medicine,  which  has  become  a  critical  bottleneck 
preventing further scale-up.
4 It will also need to think of 
the longer term and make sure that more patients are 
not only started on treatment but are also kept alive by 
making second-line drugs available. A suﬃ   cient quality 
of country programmes must also be assured.
more  connected  with  the  citizens  of  this  world,  to 
better understand their needs and to share knowledge. 
Knowledge is the secret of success and should not remain 
only in the domain of a privileged few. With the multitude 
of  international,  national,  public,  and  private  agencies, 
institutions, and enterprises that are active in the health 
ﬁ  eld  today,  in  a  well-organised  eﬀ  ort,  together  with 
governments, we can all make a diﬀ  erence to the lives and 
life expectancy of millions around the world.
Every life counts and every life is important. Those with 
knowledge should help others to learn more and to use 
that knowledge for better health of the individual and 
family, and for greater social and economic devel opment 
in their country.
Kazem Behbehani
Genthod, Geneva 1294, Switzerland 
Kazem.behbehani@gmail.com
I declare that I have no conﬂ  ict of interest.
1  G8 Summit 2006 Saint Petersburg. Fight against infectious diseases. 
July16, 2006: http://en.g8russia.ru/docs/10.html (accessed Oct 16, 2006).
2  World Health Organization. The world health report 2006—working 
together for health. 2006: http://www.who.int/whr/2006/en (accessed 
Oct 16, 2006).
3  Mudur G. India launches national rural health mission. BMJ 2005; 330: 
920.
4  World Health Organization. Resolution WHA58.28 on eHealth. Resolutions 
and Decisions of the ﬁ  fty-eighth World Health Assembly. May 25, 2005: 
http://www.who.int/gb/ebwha/pdf_ﬁ  les/WHA58/WHA58_28-en.pdf 
(accessed Oct 16, 2006).
5  World Health Organization. eHealth: report by the Secretariat. 
Fifty-eighth World Health Assembly document A58/21 7. April 7, 2005: 
http://www.who.int/gb/ebwha/pdf_ﬁ  les/WHA58/A58_21-en.pdf 
(accessed Oct 16, 2006). 
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Thyolo Distrinct Hospital, Malawi
Comment1406  www.thelancet.com   Vol 368   October 21, 2006
Malaria is another priority. The painfully slow imple-
mentation at country level of artesunate combination 
therapies  (ACTs)  must  receive  urgent  attention. 
Although many countries have changed their treatment 
protocols  to  ACTs,  these  newer  life-saving  drugs  are 
still not reaching patients who need them.
5 Drugs are 
becoming  available  from  an  increasing  number  of 
suppliers but production costs are decreasing slowly. Will 
WHO play its role in ensuring the sustainable funding of 
ACTs, and challenge governmental complacency on this 
issue?
Possibly the greatest challenge facing the UN health 
agency today is the need to reverse the erosion of WHO’s 
mandate,  adapt  to  new  international  environments, 
and re-assert its leadership on health issues. WHO must 
now  deal  with  new  stakeholders:  large  contributions 
to international health are made by the Bill & Melinda 
Gates  Foundation  and,  not  surprisingly, the  inﬂ  uence 
of this single private philanthropic organisation on the 
international  health  agenda  is  unprecedented.  How 
will WHO assert leadership in view of new independent 
actors that come with vast resources?
Recent years have seen life-saving products become 
indistinguishable from any other tradable commodity, 
and  actual  health  concerns  relegated to the  point  of 
being  superﬂ  uous  during  trade  negotiations.  WHO 
has become a follower rather than a leader while other 
agencies have promoted their respective agendas. Not 
least of these agendas is the standardisation of patent 
regimens by the World Trade Organization
6 and assaults 
on ﬂ  exibilities in patent law by the World Intellectual 
Property Organization.
7
Ensuring access to medicines for those in need now 
depends more than ever on the use of ﬂ  exibilities in the 
Trade and Intellectual Property Rights (TRIPS) scheme 
enshrined in the Doha Declaration.
8 But Novartis’ legal 
challenge  to  section  3d  of  the  Indian  Patents  Act  is 
the most recent in a series of developments that goes 
against the spirit of the Declaration.
9 This challenge has 
far-reaching consequences that extend across the globe, 
threatening  access to  essential  generic  medicines  not 
only in India but also in developing countries that import 
Indian generic medicines. Will WHO take bold steps to 
defend  health  over  competing  interests,  for  example 
by promoting imple mentation of TRIPS ﬂ  exibilities in 
developing  countries,  or  will  it  again  choose  to  stay 
silent? Worse, will it continue to stiﬂ  e dissenting voices 
from its staﬀ  , as it has done in the past?
10
In April, WHO’s Commission on Intellectual Property, 
Innovation and Public Health outlined many of the key 
problems  in  research  and  development,  intellectual 
property,  and  access  to  medicines,  and  made  several 
recommendations.
11  Mandated  by  the  2006  World 
Health Assembly to follow up these conclusions, will the 
agency and its new leader have the resolve necessary 
to seize this historic opportunity, and develop a global 
framework  for  research  and  development  driven  by 
health needs and not by commercial concerns?
Our  questions  can  be  rephrased  more  simply:  will 
the  WHO’s  Executive  Board  choose  a  leader  who  is 
courageous enough to set the right health policies, even 
if that requires standing up to vested interests, including 
those of other international agencies, certain member 
states, and powerful lobbies?
Rowan Gillies, *Tido von Schoen-Angerer, Ellen ‘t Hoen
Médecins Sans Frontières, Geneva, Switzerland (RG); 
MSF Campaign for Access to Essential Medicines, 
Geneva 1211, Switzerland (TvS-A); and MSF Campaign for 
Access to Essential Medicines, Paris, France (E’tH) 
tido.von.schoen-angerer@msf.org
We declare that we have no conﬂ  ict of interest.
1  The Lancet. XDR-TB—a global threat. Lancet 2006; 368: 964.
2  The Lancet. A missed opportunity? Lancet 2006; 368: 1063.
3  MSF. Untangling the web of price reductions–a pricing guide for the 
purchase of antiretrovirals for developing countries, 9th edn. July, 2006: 
http://www.accessmed-msf.org/documents/untanglingtheweb%209.pdf 
(accessed Oct 16, 2006).
4  The Lancet. Responding to the global human resources crisis. Lancet 2004; 
363: 1469–72 
5  UNICEF, World Health Organization. World malaria report 2005: http://
www.rbm.who.int/wmr2005 (accessed Oct 16, 2006).
6  World Trade Organization. The legal texts: results of the Uruguay round of 
multilateral trade negotiations. Cambridge: Cambridge University Press, 
1999.
7  Geneva declaration on the future of the World Intellectual Property 
Organization. October, 2004: http://www.cptech.org/ip/wipo/
futureofwipodeclaration.doc (accessed Oct 16, 2006).
8  ‘t Hoen E.  Access to medicines: why it’s time to change the rules published 
in 2006 Commonwealth Health Ministers Reference Book. Henley Media 
Group, London: Commonwealth Secretariat, 2006.
9  Barraclough E. Indian patent law under question. Managing Intellectual 
Property Sept 26, 2006: http://www.managingip.com/?Page=9&PUBID= 
198&SID=653222&ISS=22437&GUID=39580051-D288-4ECF-87BB-
2D014D99D300 (accessed Oct 16, 2006).
10  Williams DC. World health: a lethal dose of U.S. politics. Asia Times 
June 19, 2006: http://www.atimes.com/atimes/Southeast_Asia/
HF17Ae01.html (accessed Oct 16, 2006).
11  Commission on Intellectual Property, Innovation and Public Health. 
Public health, innovation and intellectual property rights. April, 2006: 
http://www.who.int/intellectualproperty/en (accessed Oct 16, 2006).
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Historic Opportunity for WHO to Re-Assert Leadership.

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