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Turmoil over the future of the WHO intensified this week as its member
states prepared to decide on the organisation’s leadership for the next
five years. Fierce opposition to the present Japanese director-general,
Hiroshi Nakajima, among the WHO’s Western donors has raised speculation
that some will cut their funding or divert money elsewhere if he is confirmed
in post next week at a vote by the World Health Assembly – the annual meeting
of member countries.

Despite frantic diplomatic activity in Tokyo, Washington and Geneva
the likely outcome of the vote is still unclear. Such disarray is unprecedented
in the WHO’s history: normal practice for the 183-member assembly is simply
to rubber-stamp the recommendation of its executive board. The board elected
Nakajima by 18 votes to 13 in January after a bitter campaign in which he
was opposed by the US and European Community and supported by Japan and
many developing countries. (This Week, 19/26 December). Nakajima’s opponents
criticise his management style.

Only days before the start of the assembly, many states were still undecided
about how to vote. Fear of damaging relations with Japan has left some Western
nations paralysed by disagreement within their governments over the relative
importance of diplomatic relations and health. ‘The US has made no decision
on the election,’ said Harold Thompson at the US Mission to the United Nations
in Geneva.

European Community countries have also failed to reach a consensus although
sources say a majority will vote against Nakajima. Yet even if all those
who opposed Nakajima in January vote ‘no’ next week, he is expected to win,
thanks to support from African, Latin American and Asian countries.

Since last month, when the WHO’s external auditor published a damaging
report into the organisation’s finances (This Week, 10 April), Japan has
come under intense pressure to withdraw Nakajima’s candidacy or demand changes
in his senior staff. The report revealed ‘shortcomings’ in the way funds
were spent in the year leading up to the executive board’s election.

Diplomats say Japan is embarrassed by the report and that its government
has pressed Nakajima to make changes. A spokesman for the Japanese foreign
ministry said the report had found no evidence of fraud or ‘serious violation’,
but added that Japan ‘regrets that there are several shortcomings in the
use of its (Japan’s) extrabudgetary contributions’ for what it calls ‘questionable’
contracts. Japan ‘will shortly make representations to WHO to ensure the
proper use of the contributions of all member countries’.

Privately, diplomats elsewhere say the Japanese government wants to
save face, not by withdrawing support from Nakajima, but by finding another
way to placate Western donors. According to one source, several strategies
have been discussed. One possibility is that Nakajima might be asked to
retire early; another is that he could be surrounded by influential ‘advisers’.
Sources close to the Japanese foreign ministry have denied plans for such
compromises.

Health officials in the US, Britain, Denmark and France strenuously
deny claims that their governments will cut funds to the WHO or withdraw
their membership if Nakajima gets back in. Thompson said: ‘We absolutely
are not going to withdraw from the WHO and we have no plans, and there has
been no discussion, about cutting back on our voluntary contributions.’

But there is speculation that ministers will lose faith in the WHO if
its leadership is perceived as weak. Some believe the first casualties will
be the WHO’s programmes in tropical medicine, human reproduction, AIDS and
child health. A British health expert said: ‘Nobody will believe anything
that has the WHO imprimatur on it, and that is very important because there
are a lot of scare stories and we need leadership.’

One possibility is that other agencies such as the UN Development Programme
or UN children’s fund will attract donors’ funds. ‘There is strong competition
between the different UN agencies for donor money and the best wins,’ said
Jorgen Varder, Denmark’s representative on the executive board. ‘That is
a problem for the WHO at present.’ The first meeting of the new executive
board is expected to demand sweeping changes in the WHO’s management before
January.