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http://www.nytimes.com/2003/01/28/health/policy/28WHO.html?tntemail0

Changing of Guard at W.H.O.

By ELIZABETH OLSON

hen she took charge of the World Health Organization four and a half years ago, Dr. Gro Harlem Brundtland was certain that she would move health issues to the top of the global agenda and leave her no-nonsense imprint on the giant, troubled agency.

Known simply as Gro in Norway, the brusque physician had been a dominant force there for more than a decade — the first woman to become prime minister and the youngest person to hold the post. Her report on sustainable development, which led to the 1992 Earth Summit, had earned her international renown.

A Harvard-trained public health expert, Dr. Brundtland began her tenure as director-general of the United Nations agency seeking to convince governments that addressing the cost of disease was crucial to economic growth and development in poor countries.

To some extent, Dr. Brundtland has met her goals, but progress has not been quite as linear as she envisioned, and perhaps has even been undermined by her unexpected announcement that she will leave after one term.

Dr. Brundtland's successor is expected to be chosen today in Geneva at the agency's world headquarters by the organization's executive board, which represents 32 nations.

Dr. Brundtland helped the United Nations health agency, founded 55 years ago, after World War II, reclaim its credibility with a series of high-profile initiatives, but seemed to stumble when it came to reforming its structure.

When Dr. Brundtland started in 1998, many believed that if she could reinvigorate an agency beset by accusations of cronyism and petty corruption, she might well step up to a higher office, perhaps even secretary general.

The first woman to head the agency, Dr. Brundtland bolstered that notion by moving quickly into the spotlight, announcing a campaign for a treaty to curb tobacco use, an effort to roll back malaria's resurgence, and alliances with pharmaceutical companies to donate vital medicines to some countries and cut the price of others.

She galvanized governments, and some private donors, into giving more attention to "diseases of poverty," including AIDS, tuberculosis and malaria. She encouraged W.H.O. to tackle obesity and other "lifestyle" diseases by focusing on guidelines for diet, nutrition and physical activity.

"Health and health care were really outside the political agenda," said Dr. Mohga Kamal Smith an Egyptian doctor who tracks health issues for Oxfam, the international relief organization. "No one was shouting about it until she put it on the international agenda."

For all her visibility, Dr. Brundtland has been frustrated in efforts to revamp the 4,000-employee agency. Reform has been fitful, and discontent pervades the staff ranks.

In August, Dr. Brundtland confounded admirers and critics, bucking the United Nations tradition of repeat candidacies, by announcing that she would depart at the end of her five-year term. At 63, she said she had dedicated three decades to public service and wanted to spend time with her family.

Her announcement left "a feeling of disappointment and desertion," said a top agency official who admires her. "We are right in the middle of our budget, and in the middle of reforming W.H.O.," he said.

"W.H.O. used to be a rat's nest of fiefdoms and political patronage," said Nils Daulaire, head of the independent Washington-based Global Health Council. "That has started to change, but it's not complete."

Dr. Brundtland, in a telephone interview, insisted that reform would remain her top priority until she left in July.

"I want to ensure that the work which has been going on over the past five years is seen to completion, or followed up until I can hand it over to my successor," she said. Another main goal is wrapping up the anti-tobacco convention, she said. She said she expected disagreements to be worked out before May, when the agency's 192 member countries hold their annual meeting. At the session, members are expected to approve W.H.O.'s first treaty on curbing tobacco use.

Antismoking campaigners credit Dr. Brundtland with taking on tobacco as a major preventable cause of millions of deaths each year. Even though they fear a weak treaty, the campaigners do not blame Dr. Brundtland.

Judith Wilkenfeld, international programs director of Tobacco-Free Kids, praised Dr. Brundtland, saying that "the genius that she added to W.H.O. was the ability to motivate good people and make things happen."

Others are not so sure. Doctors Without Borders, the Nobel Prize-winning group based in Paris, has questioned partnerships that Dr. Brundtland has forged with the corporate sector, in particular the pharmaceutical industry. Critics say that accepting corporate cash threatens to compromise the agency's reputation and priorities.

"Companies have negotiated a seat at the table when policy is made," said Daniel Berman of Doctors Without Borders. "They are the vendor, or supplier, and it doesn't make sense that they are also the decision makers."

On the contrary, said Dr. Harvey Bale, who heads the International Federation of Pharmaceutical Manufacturers Association in Geneva. Dr. Brundtland "has not become subservient, or compromised W.H.O.," Mr. Bale said.

Brushing off criticism, Dr. Brundtland said: "We cannot just have people dying. We asked industry to lower prices. In my mind, there is no contradiction."

Critics of the agency also complain that W.H.O. cannot be effective without taking a more hands-on approach to deal with diseases. Dr. Smith of Oxfam said that Dr. Brundtland "didn't put her muscle behind strengthening health services."

"They are saying the right thing," she said, "but what does it mean on the ground?"

Dr. Richard Horton, the editor of the London-based Lancet medical journal, which monitors the W.H.O., has written that the agency avoided the "challenges of an African continent in collapse through H.I.V./AIDS, humanitarian disasters, and the adverse effects of corrupt governments on their people's health."

With money to tackle the AIDS epidemic "abysmally low," Dr. Brundtland said, W.H.O. can only "provide technical leadership and can advance change in areas like AIDS, TB and malaria."

"You can't just give out tablets on the street," Dr. Brundtland argued.

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