Physician heal thyself POLEMIC

Liz Hunt reads between the lines of yesterday's WHO report

The world's biggest killer lurks somewhere near the bottom of the list of the International Classification of Diseases. It is called extreme poverty, and more than one-fifth of the 5.6 billion people on the planet are suffering from it.

Sounds familiar? The link between poverty and poor health is well documented, yet yesterday the World Health Organisation published a glossy 100-page report on global health which came to the not exactly stunning conclusion that millions of deaths could be prevented by more aid and commitment from richer countries.

WHO's stated aim with this report, packed with mind-boggling statistics, bar charts and graphs, is to "confront the global community with what is happening in health", and to galvanise public opinion to bring pressure to bear on governments reluctant to invest in health care at home or overseas. It contains little that is new.

"Poverty is bad for health, we've known that for years," admits Dr John Martin, a public health specialist at WHO's headquarters in Geneva. And WHO has regularly presented the results of global health surveys to the healthcare professionals, he says. So why this report for general consumption and why now?

The answer is a PR offensive by WHO and the clues lie in the fact that two of the four chapters of the report taken up with the organisation's evolution and history, and its "contributions to world health".

For the past five years WHO has endured one of the rockiest periods in its 47-year history, under the leadership of one of the most unpopular director-generals ever. In the run-up to the re-election of Dr Hiroshi Nakajima from Japan as director-general in 1993, there were bitter accusations of corruption within the organisation. Britain's National Audit Office conducted an investigation and concluded that there were "shortcomings in contract letting" and a lack of accountability.

European countries and the US bitterly opposed Dr Nakajima's reappointment on the grounds that he lacked the communication skills for the job, that he spent too much time travelling, and alleged favouritism in appointments to senior positions. His supporters say he is a skilled manager and competent administrator who has to travel to fulfil his duties to WHO. However, morale sank to an all-time low before the re-election, and then took a sinister turn. Elevators in WHO buildings were defaced with graffiti proclaiming "Death to Nakajima" and a prize Japanese carp, nicknamed the "director- general", was found dead and gutted in the reflecting pool near WHO's headquarters in Geneva.

Critics said WHO's output on major projects slowed. Next week another report from the National Audit Office will criticise various WHO activities in Africa.

WHO faces a "critical" financial situation, according to one insider. Like its parent organisation, the United Nations, it faces a shortfall in "subscriptions" and extra-regular contributions from many of its 190 member nations.

Over the next 10 days the World Health Assembly - effectively WHO's parliament - will wrestle with the proposed budget of $1.8bn over two years, the tightest yet. A jobs freeze is already in place and more jobs are threatened. "What makes WHO work is its brain power, the people who work for it, and that is what we are trying to preserve," a spokesman said yesterday. "We are trying to cut costs wherever we can."

Dr Nakajima describes the World Health Report as his "personal responsibility". It was presented with pomp and ceremony to the World Assembly yesterday. By reminding people of what WHO has achieved, and detailing what remains to be done, Dr Nakajima was making a plea for clemency and cash at a time when overstaffed, over-bureaucratic organisations are under threat everywhere. In doing so, WHO's once popular slogan of "Health for all by the year 2000" was quietly laid to rest.