Recent events at WHO prove bigger is not always better

I have always admired great humanitarian organizations, the World Health Organization (WHO) being one of them. They mostly help the poor and distressed in the world.

The WHO headquarters in Geneva has focused on health issues of global concern since 1948. Six regional offices in Europe, America, Africa, the Middle East, and Asia (two offices) concentrate on technical support and building national health competence, while 147 national offices maintain close relationships with ministries of health.

The WHO's main headquarters blends the modernistic functional style of early postwar French-Swiss architecture with the ideals of a garden city. A pleasant park-like landscape stretches down undulating hills above the city of Geneva and Lake Léman. Inside the main building, you learn rapidly how short-lived contemporary architecture can be. The sterility and staleness is even worse in the adjacent office buildings, connected to the main hub by long underground corridors. Gray staircases lead upwards to rows of small offices, each one usually shared by several employees. They are furnished without much care. Shabby gray metal office chairs and desks add to the gloom.

Smile, and the world smiles too. There is nothing like a warm and confident smile to create a good first impression. I realized early on during my collaboration with the WHO that hardly any of the people moving purposefully down the corridors in Geneva smiled. All faces were serious, restrained, tight-lipped. I assumed that this manner came with the important and wonderful tasks that people were working on. They are coldly efficient, I thought.

My contact with the WHO dates back 25 years, to the time of the “great leap forward” in radiology. CT and ultrasound had just entered the clinical arena; MRI was seen as a promising new tool. The collaboration was close and good at times. At other times it was cooler and more distant. I was at the forefront of research and application. Some people at the WHO headquarters and at the regional office in Copenhagen were interested in the possibility of integrating high-tech imaging into the world's health systems. We arranged some conferences together before they left the organization. I moved on too.

I became involved with the WHO again a few years later, this time in relation to basic x-rays. Trauma, chest disease, abdominal disease, and pregnancy are the most common indications for diagnostic imaging worldwide. Plain radiography accounts for over 90% of all necessary examinations in small rural or suburban hospitals, with ultrasound satisfying a large part of the remaining 10%. Together these modalities are all that is needed for 70% to 80% of all diagnostic imaging, even at university hospitals.

IMAGING FOR ALL

Medical imaging is a vital part of the diagnostic process. Every patient should have the right to receive diagnostic imaging when their physician or healthcare worker believes it will assist diagnostic accuracy and improve treatment. Diagnostic imaging should not be a rare privilege.

Yet more than 100 years after the discovery of xrays, approximately two thirds of the world's population does not have access to the most basic diagnostic imaging service. The WHO's fundamental principle of “health for all” is equity, which demands that diagnostic imaging be made universally available to all who need it. This would allow diagnoses to be made quickly and accurately, reduce hospitalization times, allow patients to return home or to work promptly, and, most important, result in less pain and suffering.

Today's global market for electromedical and healthcare IT equipment is worth €39 billion, according to COCIR (Facts & Figures: www.cocir.org). This breaks down into €20 billion for radiological and electromedical equipment and €19 billion for healthcare IT. Pharmaceuticals, including contrast media, add another €6 billion (Nunn A. The cost of developing imaging agents for routine clinical use. Invest Radiol 2006;41[3]:206-212).

About 75% of this sum is spent by 20% of the world's population in countries with market-driven healthcare systems. These include many European Union countries, the U.S., and Japan. Developing countries that have need-driven healthcare systems spend a quarter of this sum on diagnostic imaging equipment and accessories.

Ten years ago, the radiologist in charge of diagnostic imaging at the WHO built up a small circle of referees to read pediatric x-rays acquired in Africa and Asia as part of a project to monitor the impact of vaccinations against pneumonia. It was a worthwhile and successful endeavor. This small team also promoted the World Health Imaging System for Radiography (WHIS-RAD), which had been developed according to the WHO's technical specifications. The idea behind WHIS-RAD was a low-cost, safe, reliable, easy-to-use x-ray system that would produce high-quality images. It was good value for little money.

Although the WHO cannot provide equipment, it can help operators use the machines properly by improving knowledge. WHIS-RAD (and digital WHIS-RAD) equipment was subjected to extensive clinical testing by collaborating centers in Sweden. The concept was put to the test all over the world, with centers of excellence being set up in Africa and Fiji.

An outstanding set of manuals accompanied each x-ray unit. They described how to perform procedures, process the films, interpret the results, and take care of radiation protection. The WHO also produced workbooks and manuals for end-users, whether radiologists, general practitioners, or radiographers. These booklets can be included among the best teaching materials available on radiography and ultrasound. They are simple, to the point, and cover most questions of daily medical life.

The last person to head diagnostic imaging at the WHO retired in 2007. The organization had already, in 2006, put a moratorium on filling the vacancy. The position was finally announced in 2008, but in the following year all applications were rejected and the position frozen again. Ongoing projects in Africa collapsed in the meantime and other projects were put on hold.

The official reason given for shutting down diagnostic imaging in the WHO was lack of money. Off the record, the reasons ranged from personality clashes, internal power struggles between directorates, external lobbying, incompetence, and indifference to plain unwillingness to work.

The mills of the WHO's admirable bureaucracy grind slowly. There is more intrigue in a small WHO department than in a 500-page romance novel. The position in medical imaging is a lonesome place; there is hardly any in-house collaboration. Just one person is responsible for the teaching and training of x-ray, ultrasound, and all other imaging modalities-worldwide.

Medical imaging is considered within the WHO to be a marginal medical service discipline. Imaging is not regarded as a priority in primary healthcare and this is reflected in staff numbers. The WHO employs 8000 people worldwide but there is just one position for medical imaging.

It is difficult to find a person to fill the WHO's medical imaging post. The ideal candidate would have at least 20 years experience in medical imaging and medicine at large, and an awareness of the problems facing healthcare systems in developing countries. He or she would be knowledgeable, critical, and incorruptible, have a strong personality, and be fluent in several languages. She or he would also be willing to put up with the bureaucracy, vanities, and listlessness of the WHO administration and to travel extensively in “non-touristic” countries.

Although the job is not well paid, the post holder would be based in Geneva, one of the most expensive cities in the world. Working conditions are often lamentable. Idealism helps.

TALKING SHOP

I received an e-mail toward the end of 2008 from the WHO asking if I would be interested in coorganizing a conference on the organization's role in diagnostic imaging. I was astonished. The radiology position at the WHO had been vacant for nearly two years at this point. There was nobody in the entire organization with a background in diagnostic imaging.

More than 30 people from all corners of the world were invited. They assembled in Geneva for three days of lectures and debate. The overview of diagnostic imaging they presented was the widest and (in some instances) the most tormenting I have ever been confronted with. This was not a view into the future of market-driven imaging, as is often presented in Chicago at the annual RSNA meeting or in Vienna at ECR, a surreal looking-glass for most regions of the world. People working for the WHO were instead given an impression of what a United Nations agency should attend to.

Yet the outcome of the meeting is nil. Incomprehension and disappointment was written across the faces of participants on the last day of the conference. Only afterwards did it become clear that the meeting's aim was not to benefit mankind. It was to gag possible critics, play power games within WHO, get even on old scores, and (last but not least), spend the allocated budget so that it wasn't lost in the future.

The withdrawal of the WHO from an entire medical discipline is detrimental to public health all over the world. The organization fails billions of people worldwide, and this failure is painful. Neither the director-general of the WHO, nor the assistant director-general in charge of diagnostic imaging responded to e-mails or letters from major professional and nongovernmental organizations (NGOs) expressing their concern and offering advice, help, and support.

A number of small organizations, mostly NGOs and government institutions, but also small companies, have tried to fill the gap. Among them are the World Health Imaging, Telemedicine and Informatics Alliance (WHITIA; www.worldhealthimaging. org), The Round Table Foundation (TRTF; http://trtf.eu), and the Swiss Tropical Institute (STI; www.sti.ch/).

WHITIA appears to be the most active at present. It is a nonprofit entity attacking the problem of providing communities in resource-poor areas worldwide with access to low cost digital imaging equipment. The backbone of the alliance is a small business-like administration in Chicago. They cooperate with local health authorities, global NGOs, academic institutions, and the imaging industry.

All of the small organizations involved have dedicated people and efficient structures. They handle problem-solving and decision-making rapidly. One of their main assets is competence.

The WHO, on the other hand, is a huge administration that is lacking proper control of its internal structures and is wracked with turf battles between different departments. It is a political enterprise with 193 member states. Irrelevant third-party considerations count more than outcomes, responsibilities are fragmented, decision-making processes are complicated and protracted, and there is a distinct lack of authority. Genuine political techniques, such as obtaining loyalties and securing allegiances, hamper or are given priority over solving the primary problem.

Small is beautiful.

Disclaimer: Many people are putting all their efforts into the ideas behind the United Nations and their agencies because they believe in them. Let us support them. A little smile may be sufficient to trigger a change in mind and allow continuity in the WHO's work.