African Health Sciences Makerere University Medical School ISSN: 1680-6905 EISSN: 1729-0503 Vol. 10, Num. 3, 2010, pp. 390-394

African Health Sciences, Vol. 10, No. 4, December, 2010, pp. 390-394

Practice Points

"Basically a house of experts: the production of World Health Organization information"

*Tara Das

Stiteler Hall, University of Pennsylvania, Philadelphia 19104

*Correspondence author: Tara Das, Independent Scholar, Stiteler Hall, University of Pennsylvania, Philadelphia, 19104, tara.das@gmail.com

Code Number: hs10071

Abstract

Introduction: The World Health Organization (WHO) is widely regarded as the preeminent international authority on health and scientific matters. Its information mandate is a powerful one, for it enables the WHO to construct issues as legitimate ones for concern that should be addressed in particular ways.
Methods: Intensive interviewing of WHO staff was used to elicit writing and editing processes. Approximately 25 people were interviewed repeatedly from year 2004 to 2005 using the snowball sampling method.
Results: A core staff in headquarters dominates the selection of topics, writing and editing activities. The authority of senior management in headquarters emerges as more significant than that of country leaders and representatives.
Discussion: In contrast to sister UN agencies, WHO staff prioritize collaboration and input from science and health researchers over that of UN colleagues and its internal editors. Senior management participation ensures stability in WHO information over time and adherence to the WHO scientific mandate across documents.

Key Words: HIV, AIDS, WHO, UN, information, publications

Introduction

International organizations disseminate vast amounts of information via research, writing, and publishing activities. These processes, in presenting social problems and solutions in particular ways, influence country policy debates and agenda settings. This study focuses on the World Health Organization (WHO), because it is internationally recognized as an expert house of scientists and physicians. Their statistics, reference manuals, and policy recommendations are widely cited and utilized by physicians, political officials, researchers, and NGOs. However, the organizational processes, by which WHO health and scientific documents are produced, have been little examined. This study does so, with a focus on HIV/ AIDS documents published by WHO.

The respect given to WHO and its HIV/AIDS information can be demonstrated with a few illustrations. For instance, in Uganda, the Association of the Promotion of Traditional Medicine (Prometra) was created in order to heighten the legitimacy of traditional HIV/AIDS treatment and to develop collaboration between modern and traditional medical research. It has been dispensing Metrafaids for treating AIDS since the early 1990s, which, Prometra claims, has proven effective with no adverse side effects. Underscoring the authority of WHO, Prometra's chairman Dr. Yahaya Sekagya has cited WHO policies in justifying administration of herbal HIV/AIDS drugs. "When challenged on how Prometra can administer Metrafaids, without conducting safety and efficacious scientific research needed of every drug, Sekagya said the World Health Organisation (WHO) had relaxed certain conditions for traditional medicines"¹. In Kenya as well, the WHO is referenced in discussions over the use of traditional medicine to treat HIV/AIDS. The Kenyan government has urged researchers and scientists to carry out tests on investigational drugs according to specified WHO procedures. For example, Fares Kuindwa, Secretary to the Cabinet, cautioned, the government would continue to support and encourage local initiatives in the global effort to find a cure for AIDS. He urged scientists and researchers to strictly observe professional ethics while carrying out these tests as specified by the ministry of health and the World Health Organization².

The WHO is widely regarded as the preeminent international authority on health and scientific matters. This point means that the research and writing activities that go into WHO documents and publications warrant further investigation. The UN-wide information mandate is a powerful one, for it enables WHO and other international organizations to construct issues as legitimate ones for concern that should be addressed in particular ways. A literature in sociology on social problems has elaborated on this theme^3,4,5,6. Broadly speaking, certain conditions are identified as social problems with particular characteristics, not due to their intrinsic nature, but via actor-imposed frames, which impose meaning and guide action.

In sociology, Snow and Benford were instrumental in the mid-1980s in extending Goffman's frame analysis to social movement organizations in discerning how cognitive processes, identity formation, and culture are of influence in protest activities⁷. Frames are "schemata of interpretation" that imbue experiences and events with specific meaning for individuals and groups. Frames are neither arbitrary nor neutral. Rather, they are cognitive guides or structures, which indicate what is important to observe, and by directing attention away from other possible interpretations, indicate what is unimportant. Frames aid in interpreting phenomena by defining the problem that requires redress, identifying its causative factors, and suggesting reforms and policies in accordance. With the use of frames, people are able " 'to locate, perceive, identify, and label' occurrences within their life space and the world at large" ⁸.

Among the international organizations that have been at the forefront in addressing HIV/AIDS are the WHO, UNAIDS, and the World Bank. The WHO, with its Global Program on AIDS in 1986, took the initial lead in constructing an international response to HIV/AIDS once it became evident that the disease was not confined to wealthy, industrialized countries. However, with its mandate being exclusively health and science-related, and other UN agencies clamoring for responsibility, UNAIDS, a joint agency created in 1996, was established in order to better coordinate international actions. The World Bank, the lead financier for HIV/AIDS projects, began focusing its efforts in 1992.

Each of these organizations has constructed in-depth arguments that center on their organizational mandate: WHO - epidemiology; UNAIDS - human rights; and the World Bank - socioeconomic development. Yet they also all touch upon epidemiology of HIV/AIDS; the threat to development; the need to reduce poverty and elevate the economic and legal status of women to counter epidemics; prevention over treatment; and the need for political commitment. Language and representations utilized by groups and organizations are thus meant to persuade and generate collective beliefs and identities, which are necessary before mobilization can ensue. This study investigates how such language and representations are developed at the WHO by examining its writing and publishing activities, and the attitudes of those who engage in them.

Methods

This study is qualitative, anthropological, and exploratory in design, since the issue of how UN organizations write and edit scientific publications has been little investigated. The questions were openended and intended as guides for subjects in their explanations of processes. These questions included asking - Who selected topics for publication? Who was primarily responsible for writing (e.g. consultants or permanent staff)? Who gave final approval for publications? The subjects were senior staff, initially identified by the WHO information center and subsequently via snowball sampling, who were directly involved in writing and production of publications. Approximately 25 people were interviewed repeatedly from year 2004 to 2005. The objective was to identify the key parties and the decision-making protocols involved in the production of WHO information. 

Results

WHO Institutional Setting

The WHO is the UN specialized agency for health, and was created in 1948. Its constitutional mandate is to ensure the highest possible level of physical and mental health in people worldwide, which is integral to achieving peace and security. The WHO is largely staffed by about 3500 scientists, doctors, and other health professionals with approximately 75 in the HIV department. It is a normative agency that sets standards and benchmarks for public health, and provides policy and technical guidelines to be used by health systems around the world. Staff in the WHO regards the provision of normative and technical guidance on scientific, medical, and health related issues as one of their primary missions. Thus, writing and publishing guidelines are considered priority activities.

Christine* (all names have been changed), a WHO and UNAIDS freelance writer, remembers her experiences in editing and writing early WHO documents during its Global Program on AIDS in the 1980s.

I've been writing for a very long time. I started as a freelance writer in 1983. I wrote to someone at WHO and started editing several publications like the World Health Forum. It was pretty turgid stuff. I had to turn it into readable...Then in the mid-80s, I started writing for them...The chief publications lady in AIDS was a very good friend of mine. I got more and more experience in AIDS...In the early 1990s, I wrote on AIDS and HIV for the general public. At that stage, [WHO] had lots of technical documents but nothing for the general reader. I worked on that.

However, this editing process was discovered to be too time consuming for the central Office of Publications, and the office was dissolved upon a review of documentation procedures. Theresa, senior technical editor, relates, "An increasing amount of funding was being available to technical units, which were not part of the regular WHO budget. They were increasingly available to do their own documentation. The official channel got bypassed. Get it out, get it out, get it out. The result was that they [documents] were at variance with house style." Ayana, her former colleague, simply states, "The responsibility for publications is to individual clusters. They assumed all responsibility, including editing and following manuscripts through."

When later interviewing scientists and physicians in the HIV department, I discovered that freelance writers are frequently hired to do the formal writing, yet do so in consultation with the scientists who are responsible for the research and administering the particular document. The editorial staff provide less input than was previously the case. This information was not immediately offered to me; it emerged when I asked interviewees to guide me through a step by step process of making a document. Yet it explains the strongly scientific and technical bent of WHO publications.

Publishing from the HIV/AIDS physician and scientist perspective

There is little direct communication between scientists who originate HIV/AIDS documents and editorial staff. Communication is mediated through the HIV information center. The WHO HIV information center coordinates interactions between the HIV departments and technical editors, and sends publications for design layout and printing. Jennifer, the HIV/AIDS information documentation assistant, articulates, "Editors don't engage in direct consultation with the group. They will forward questions to the technical director, but they don't interact directly. They go through me. I hire technical editors and writers." Despite the emphasis on style from the WHO in-house editorial staff, there are some scientists who are contrary.

In illustration, Mark, head of the testing and counseling team within the WHO prevention team, frankly admits, "When I was head of UNAIDS in India, I published anyway I liked and pretended that I lost the style guide." Paulo, a physician in the Sexually Transmitted Infections (STI) focus group, says, "I have an in-built aversion to the style guide. It's often quite boring but I see the advantage to having corporate style." Nonetheless, when asked about their hiring requirements for freelance writers and editors, it is expected that the latter will have read publications by the WHO as well as by other UN agencies. Chiara, a medical scientist on the HIV prevention team, tells, "All departments have a list of writers, editors, technical editors. We work with external writers that we know have experience writing about HIV, who have familiarity with HIV and the WHO approach and style, and WHO views on these issues." Raoul, a physician on the care team, affirms, "Writers and editors read publications by other agencies, definitely."

Nevertheless, interactions with international medicine and science experts are considered more important. Bharati, who works in HIV communication and provides media releases on the 3 by 5 initiative³ million to have HIV treatment by 2005] avers, "It can become pretty arcane. The levels of technical specialty are often exquisite. The medical officers go to people who will give good input." Within the cluster, the selection of topics is based on the latest advances in scientific, technological, and pharmaceutical research about HIV/AIDS. When I ask how topics are chosen for HIV/AIDS documents, Mark provides a lengthy response.

I can't speak for other departments. WHO fulfills a number of functions. Its mandate is to improve the health of countries, which means that in many ways, it's uniquely tasked with providing the normative guidance for ministries of health around the world, that use that as a gold standard for developing own policies. In HIV/AIDS, all of the teams will determine the priorities for insuring that departments of health have the necessary information to make the most of the latest advances in research about HIV/AIDS.

As a result, it is imperative to respond to proven interventions and scientific advances. Chiara, who is also part of the prevention team, offers one example. "We know that the use of rapid tests is vastly preferable to laboratory-based methods. Being aware of that, and that countries don't have policies on use of rapid tests, we agreed that we should give the world information about rapid tests. We were responding to advances in sciences and imperatives of the 3 by 5 program."

Nevertheless, topics also emerge based on country experiences. Mildred, a medical officer who works in the country support team, focuses more on interactions with country representatives than with international experts. She describes her responsibilities in terms of publishing as the following. "The country support team comprises people who liaise directly with countries. We are the mouthpiece of countries and regional offices and coordinate activities at the country level. I'm in touch with country officers on a daily basis so I quickly learn what countries need to plan better." Paulo, in the STI focus group, corroborates, "Another WHO major mission is to give country support. To adjust or create a specific guideline, regional and country representatives can be contacted. We might suggest someone to go over from headquarters to help." Still Mildred makes sure to say that on the country support team, "We know the kinds of information to give to countries, but we still require international consensus so that advice on policies and procedures is suitable." Thus while WHO medical staff acknowledge diverse countrylevel experiences, they give greater weight in their documents to scientific expert findings. Hence it is easier for WHO information to remain consistent over time and across documents.

Mandate awareness and collaboration

UN-wide norms of collaboration and consultation necessitate staff to be versed in the mandate of their specific organization as well as those of sister agencies, so that they know over which aspects of international issues they can claim ownership. WHO staff are very clear on which issues are under their domain. Carlos, who works on the 3 by 5 initiative, relates, ?We want to establish global guidelines. That is the primary mission of WHO.? Likewise, Paulo, in the STI focus group, says, ?WHO?s mandate is to improve the health of countries, which means that in many ways, it?s uniquely tasked with providing the normative guidance for ministries of health around the world.? After querying what the staff member?s duties included, how topics were chosen, and what kinds of editing concerns did s/he have, I would mention how I was struck by the similarity in language and arguments made in later publications by WHO, UNAIDS, and the World Bank. It is here that several staff members would assert the necessity for freelance writers to be well-read in UN-wide publications, particularly those relevant to the topic at hand. Collaboration on international documents may be more likely with HIV/AIDS, which is now encouraged through the creation of UNAIDS, a joint UN agency that consists of co-sponsoring sister agencies. Nonetheless, in contrast to staff of sister UN organizations, WHO staff are more likely to collaborate with their science and health colleagues than other UN staff. As Mark asserts in the below quote, WHO staff will seek input from UN organizations, but that will not always happen as staff regard the WHO as basically a house of experts.

We go to a lot of trouble to make sure that our sister agencies have their say on specific publications. If we didn?t, the publications would lack authority. It's a very important part of the production process, but it's notgoing to happen with all the agencies all the time. In all areas of technical specialism - WHO is basically a house of experts, some in pretty arcane fields - all of us are technical focal points and have partner focal points in major agencies. [I interject and ask what a focal point is.] I know who is responsible for testing and counseling in all the major organizations and go straight to that person. Our areas overlap.

Discussion

The WHO is widely regarded as the preeminent international authority on health and scientific matters. Hence WHO research and writing activities warrant further investigation. The intensive interviewing elucidates observations, about the production of WHO documents and publications. A core staff in headquarters dominates the selection of topics, writing and editing activities. Despite there being editorial staff at WHO, it is the scientific and technical staff who dominate these activities. Moreover, several officials communicate the participation and input from country representatives, particularly in selection of topics. However when they delve into further detail, sometimes delineating the origins of specific publications, the authority of senior management in headquarters emerges as more significant than that of country leaders and representatives. The presence of WHO editors and use of UN-experienced freelance writers account for similarity in WHO publications with those of sister UN agencies. However WHO scientific staff prioritize collaboration with science and health researchers over UN colleagues, which underscores WHO independence from other UN agencies. Senior management participation also ensures stability in WHO information over time and adherence to the WHO scientific mandate across documents.

References

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2. The East African. New Cure or Old Story? The East African. March 11, 1996.
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7. Snow DA, Benford RD, et al. Frame Alignment Processes, Micro-mobilization and Movement Participation. American Sociological Review August 1986;51: 464-481.

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