Subject: U. N. 's Health Agency Finds Funds Shrinking While Work Expands Date: Published: 4/7/88 209 lines Source: WALL STREET JOURNAL. Copyright Dow Jones & Co. Inc. Money Squeeze: U. N. 's Health Agency Finds Funds Shrinking While Work Expands --- WHO's Fight Against AIDS, Other Killers Is Weakened As U. S. Withholds Dues --- Ads Touting 'Zero Grazing' --- By Philip Revzin Staff Reporter of The Wall Street Journal GENEVA -- On the sixth floor of a gray-glass office building here, highly paid international civil servants use brightly colored maps to chart the spread of acquired immune deficiency syndrome to 85,273 people in 137 countries. Halfway across the world, in the slums of Karachi, Pakistan, an unpaid health worker approaches another map. It is stuck with little red pins identifying the shacks that house severely malnourished infants. Triumphantly, she pulls out the last pin from the 150-household section she oversees. Then, smiling underneath her veil at having saved another child, she returns to the battle. The bureaucrats in Geneva and the woman in Karachi work with the World Health Organization, and they all have the same problem: too many sick people and not enough money. The WHO, a United Nations specialized agency founded 40 years ago, has pledged to bring "health to all" by the year 2000, but it isn't going to make it. In fact, because of financing cuts, the agency's resources may be shrinking, putting it even further behind in its battle against AIDS and the world's other big killers -- diarrhea, which kills 3.5 million children a year; measles, which kills two million; and malaria, which kills a million more. The U. S. is temporarily withholding its dues from the United Nations for political reasons, and that has affected relatively apolitical UN agencies like the WHO. While the U. S. gave $9 million in cash and condoms to the AIDS program in 1987, it owes the WHO nearly $113 million for its general budget. Since its founding in 1948, the WHO has been both effective and controversial. It wiped out smallpox in 1977 following a 10-year, $300 million campaign. But it has angered multinational companies recently with campaigns against infant-formula marketing techniques in the developing world, a strong anti-smoking program, and proposed moves that drug makers say could limit the distribution of pharmaceuticals in many places. "There has been a tendency to try to turn the WHO into a sort of super international regulatory body," says Alan Keyes, a former U. S. assistant secretary of state in charge of international organizations. "But now that they have a mission, a sense of purpose on AIDS, maybe that will help refocus their efforts." WHO officials say that they never lost their sense of purpose, which is to fight ancient scourges such as malnutrition and modern ones such as AIDS. The current money squeeze "is madness," says Joshua Cohen, an adviser to WHO's director general, Halfdan Mahler. "We've had to freeze key programs, cancel meetings, postpone trips -- we're living from hand to mouth," Dr. Cohen says. "Yesterday I had to scrape up three secretaries for the AIDS group -- but how am I supposed to pay them? " Warren Furth, a WHO assistant director general, warns that the budget problems will soon begin killing people. A key WHO program, run jointly with UNICEF, aims to immunize every child in the world against polio, tetanus, measles, diphtheria, whooping cough and tuberculosis by 1990. The program has reached half the world's children, but because of the financing shortage, "millions of children will not be immunized and many will die because of that," Mr. Furth says. Money will be short in the fight against AIDS, too. Jonathan Mann, the director of the WHO's special program on AIDS, estimates that the WHO will need to spend $650 million a year just on AIDS by 1991, more than double the organization's entire annual budget now. The AIDS budget is separate from that of the WHO itself, coming from individual government donations. But Dr. Mann worries that if the tree withers, so will his branch. "A strong WHO is necessary for a strong AIDS program," he says. The WHO's budget problems are mainly the result of the Kassebaum amendment, which Congress passed in 1985. It temporarily withholds U. S. financing -- a quarter of the United Nations budget -- from all UN programs. The goal is to force the UN to slash its bloated bureaucracy and reform spending decisions. But practically everyone agrees that the WHO doesn't have much fat to cut. WHO lobbyists and allies in Washington have tried and failed to get the agency exempted. So far they have pried out $68 million in back dues, but that still leaves the WHO $38 million behind for 1986 and 1987 and an additional $75 million behind for 1988. "It's bizarre, crazy and terrible," says Donald A. Henderson, the dean of Johns Hopkins University's School of Public Health. "Ronald Reagan made a big pitch in Venice {at last summer's economic summit} about fighting AIDS, while the U. S. was the only country there that hadn't paid its WHO dues. They're stripping an organization we really need." Dr. Henderson helped lead the WHO's fight against smallpox, and he sees parallels with AIDS. "You've got to get health ministers to take unwanted advice. For AIDS, just like for smallpox, if you didn't have the WHO, you'd have to invent something just like it," Dr. Henderson says. What the WHO really does, its officials say, is embodied in a program adopted at a conference in 1978 in the Soviet city of Alma Ata. Called "Health for All by the Year 2000," it is a general plan for "primary health care," including better sanitary conditions and the provision of basic health services where they are lacking, to help "all citizens of the world attain a level of health that will permit them to lead a socially and economically productive life." In practice, this means setting up immunization centers in hard-to-reach villages in places like Uganda and Tibet, designing solar-powered refrigerators to keep vaccines cold, and inventing low-energy pressure cookers to sterilize scalpels. It means sending out "vaccine cocktail" recipes to fight new strains of influenza and handing out 10-page malaria questionnaires at the Nairobi airport. But mostly it means a heartbreakingly slow battle to educate people about their own health. Nowhere are the WHO's efforts and limitations better illustrated than in two current fights, one against poverty in the slums of Karachi and the other against AIDS everywhere. Scores of filthy children play in the dust in Grax, one of Karachi's ever-expanding katchi abadis, or temporary settlements, which have existed as long as anyone can remember. Here, the primary health care that WHO preaches means "knowing where your malnourished kids are," says Leslie Lee, a professor of public health at McMaster University, Hamilton, Ontario, who is working in Karachi for a year. Dr. Lee is sweating in the shade of a three-room brick medical center in the middle of a sprawling tract of paper, rag and wooden shacks, home to more than three million people. Grax has one of the world's highest birthrates and infant death rates. The percentage of people who die before the age of five is 25 times higher here than it is in the U. S. "Our biggest problem is malnutrition," says John H. Bryant, who runs the community health program for the new Aga Khan University Medical Center in Karachi. "We know the malnourished kids are out there. We watch them. And they die anyway." A 25-year-old woman in an orange and red silk dress swaddles an infant. She gives Dr. Lee her baby's chart, which shows that in the past month the bouncy, pink-cheeked six-month-old has progressed from being severely malnourished to normal. "Breast feeding," says Dr. Lee. Scores of other babies wait noisily to have their weight charts filled in by volunteer health workers. The babies will also be immunized -- 70% of Karachi's children are now protected against the six major childhood killers. "There are so many problems," says Dr. Bryant, who used to work for both the WHO and the U. S. government. "The water is so contaminated that nearly everybody has gastroenteritis. There is no sanitation. We could easily spend the entire WHO budget each year right here in Karachi and not make much of a dent." The WHO's biggest role in such situations is "providing a guiding morality," he says. "The concept of health for all is grounded in equity, to each according to their needs. It helps keep us going." Dr. Bryant glances at charts showing Karachi's appalling infant death rate. "The WHO gives us the theories, this is the practice," he says. Theory and practice merge in Dr. Mann's cramped sixth-floor office at WHO headquarters in Geneva. Because AIDS has neither a cure nor a vaccine, Dr. Mann says, the WHO's only weapon is experience. "We offer a 40-year history of conducting international campaigns. The biggest lesson of the smallpox fight was that it could be won, and not just by doctors speaking English. The WHO can talk to everybody." That's particularly important with AIDS. "The U. S. simply isn't trusted in the Third World on AIDS," says Dr. Henderson of Johns Hopkins. "We are seen, not wrongly, as the major disseminators of AIDS, and we are seen as being way behind in doing anything about it. So when a U. S. official shows up somewhere, an African or Asian official will say, 'Who are you to tell us how to set up our program? ' They'll listen to the WHO. " It takes a lot of talking. Some countries refuse to acknowledge that they have any AIDS sufferers, and others, particularly in Africa, report numbers that are obviously too low. The WHO estimates one million Africans have the AIDS virs, not all of whom have or will get the disease, while official reports list only 10,995 AIDS sufferers for the whole continent. But awareness is growing, the WHO says. Kenya recently announced that all blood for transfusions will now be screened for AIDS, and a new government ad campaign touts "zero grazing," or monogamy. Kenya's health minister was one of 114 health ministers at a WHO-sponsored AIDS conference in London last January, and the country is now using WHO money to buy more testing equipment for rural hospitals. Dr. Mann says that his trump card in spreading the word on AIDS prevention is the WHO's reputation. "It's obviously going to be harder and more expensive to control AIDS than it was to eliminate smallpox," he says. But "given what the WHO knows as an institution and with its network of health workers supporting local ministries of health all over the world, we have the capacity." [This article is made available here by Dow Jones Co. for the personal and non-commercial use of callers to this bbs, in the hope that it will be of some help to those who are suffering from the disease and others who are seeking to help them.]