Peter Pachner (WHO 1980 - 2006)

Please tell us about your youth. I was born in Graz, the second largest city Austria, in 1946. Growing up directly after the Second World War meant living in a socioeconomic setting of extreme scarcity. That changed slowly towards the 60’s but here my generation was quick to criticize the, then about to be established, waste oriented society. The cold war marked my life to a great extent. No matter what, any intelligent person at that time must have realized that whatever the conflict is about, it is always best to be on the side of the winner, but I could not really make up my mind who is or who will be, the winner. Like many young people at the end of the 60’s I dropped out of school (engineering studies) to travel, see Asia and in particular India. I ended up studying Hindi language and Indian culture in India at the Benares Hindu University. I was lucky to get support through an Austrian scholarship. It was this ten years exposure to other cultures and public life which was the main factor to make me take up an international career eventually.

So when and where did you start to work professionally? The first attempt was in 1978 , a part time job at the Deutsche-Welle. It was then also called “The Voice of Germany” and was situated in Cologne, Germany. It was a German version of the much better known (propaganda) radio station “The Voice of America”. I worked as an author and speaker in Hindi language. However, in spite of being on the air in all forms of radiofrequencies across continents I found that I was only presenting a single point of view and not listening. My conclusion was that I would be better off to work in an International Organization. This led me to Geneva and WHO. From my initial engineering background I must have had some hard-wired brain functions relating to mathematics, statistics and logic. The early 80’s was the time when computers started to hit office desks. I would amaze everyone how well I could handle these machines. And when talking statistics it led me to the Department of HST (Health Situation and Trend Assessment). It took me 4 years to get a regular job as a Statistical Assistant and another 4 years to become professional staff with a quite similar scope of work as in my previous G6 position, but a slightly lower salary 1. I was very fortunate to have Dr Steve Sapirie as my Chief. He was an incredibly hard working man. He also believed that giving a chance to younger staff and supporting their educational development was an asset to the Organization. Thus I had the chance to get for 3 years a study leave of 6 weeks each year and the study fees paid too. Having all that support, last but not least, I obtained my MPH in 1998 in Public Health from the Geneva University. Of course the theme of most of the papers was in the field of health information. It was not easy to go back to school at the age of 49 but I think it was a good investment for both, the Organization and me personally.

I am delighted by your good fortune of having Steve Sapirie as your boss. Obtaining a Study Leave was indeed not so easy. Why I got study leave and not so many others that would have deserved it too? The answer probably quite simple; Dr Sapirie himself had the good fortune to get study leave. WHO sent him (1977-78) for a Doctorate in Public Health at the University of North Carolina. Later it was my turn to support younger staff in their career and professional development. During my time in Indonesia (2000-2006) I had the opportunity to help young nationals through contracts and organizing their participation in meetings and seminars. By the time I

1 By the time I left the Organization, 20 years later, it was perceived as a scandal that (young) staff had to work for many yeas on temporary basis. I remember that in my time it was just like that.

left Indonesia one of my national collaborators became a professional in Geneva, and two of them were working on their PhD in Australia.

Tell us what you did in WHO between 1980 and 1988 When I started in WHO, it was at the same time as computers came to change our lives. The data collections I found in HST among others were handwritten cards of the office of Hygiene under the Organization of the League of Nations. The data was from 1925 onwards till the break of the 2 nd World War. It went back to countries like Dahomey, German West Africa and Tanganyika reporting tropical disease outbreaks. We also had in the early 80’s massive amounts of data related to medically certified cause of death. All that had to be organized, validated and either thrown away or computerized. Looking back I think what we did was laying out the fundamentals of the role of Personal Computers in the office which could also be called learning by making mistakes.

Then you seem to have been involved in training nationals in “developing countries” Exactly, during the period 1988 to 2000 I had numerous assignments in West and East African countries and Asia. The tasks were always related to the generation and use of information for the management of health care provision. I was trained to work in a participative style, workshops for District Team Problem Solving (DTPS), rapid assess- ments and evaluations. I strongly believe that the asset of my work was the combination of workshops and fieldwork in a highly participative style.

When you say that you “were trained to work in a participative style ” where and when was that? There was of course my hard wired sense of logic, but to apply systemic thinking in health I went myself trough a participative learning process by working with Dr Sapirie, reading relevant literature and also doing my MPH at the Geneva “Institut de Medecine Sociale et Preventive” (IMSP) with a Red Book at hand which was written by a certain J-J. Guilbert. That book had as title something related to “health personnel”; but it is also a guide on how to conduct workshops and it is a good refresher for anyone going for fieldwork.

The period that followed Mahler’s (after 1988) modified many aspects of HQ. What was the influence on your own work? In fact, the management of WHO changed twice. First Dr Nakajima and than Dr Brundtland. The leadership of Dr Nakajima was somewhat low profile. It was later criticized ‘business as usual’; however, there was little interference with technical units. We must give some credit to the style of doing little or nothing; it automatically does little or no harm. The big shakeup came with Dr Brundtland. It was the end of ‘business as usual’. That is changing and fixing everything, even the things that actually were working well. Then, around 1998 all of my colleagues of the HST Unit called Strengthening of Country Health Information (SCI) retired. The Organization went from data collection to data analysis .

Indeed, it seems a good idea: Once data are collected to analyze them. So what got wrong? What happened? For example, the World Health Statistics Annual Report was just a collection of data being printed without much data analysis . It was probably in response to the Human Development Report of UNDP in 1990 that WHO and other Organizations began to produce more data analysis in their reports. This was then very much the work of Dr A. Lopez. It was one of the core subjects then the fight against the tobacco epidemic. But with the arrival of Dr Brundtland data collection was downgraded. The support to Information Systems was stopped. Thus, the end of the “Strengthening of Country Health Information Unit”. Methods of estimates were applied. Available data were massaged to the point of creating serious controversies and negative reactions from Member states. This especially happened with the World Health Report 2000. That report introduced the Health System Performance Assessment (HSPA) method. While I fully agreed with the analytical work of data analysis and that it was wrongly neglected in the earlier days of my time with WHO, I also disagreed to abandon the support in data collection, generation and validation. After I left HQ it ironically happened that the WHO leadership changed again and the new leadership reversed the previous decisions. They send the HSPA promoters into the desert. They installed a new team to establish the health metrics approach ( data collection ). However, because of the new name, the old staff in data collection techniques was mostly left out. It is a phenomenon we find on all levels in life: a new name for the old wine makes it all happen!

You must have felt rather disappointed… You bet! Since around 1998 till 2002 data generation and validation were seriously sidelined, thus leaving me in an office with not much to do. It was time for me to revert to country level . In country offices, at least the larger ones, a technical capacity is highly welcome. An effective and a balanced approach are always welcome. At that time HQ went a bit astray of its traditional health-leadership agenda. To put health on top of the political agenda was then the flashy slogan. We all know by now that politics in general is not to be confounded with health policy . The approach of “health on top of the political agenda” had clearly no positive impact at all. In 2000 I was fortunate to find a place in the country office of Indonesia where I could apply collection methods, validation methods and promote also the assessment and data use . My position as a Monitoring Officer was perfect for this kind of support to national institutions.

Please give us a concrete example of how the Indonesians utilized your support A number of products and events had lasting impact especially in Indonesia, and I hope to some extent for the organization. The District Team Problem Solving was institutionalized in Indonesia to the point that the Ministry of Health staff was convinced that the method came from Indonesia and has been developed there. All this was very encouraging for me as I know that the only methods which work are those that are locally developed. Practical- ly all districts use the participative planning process to develop their annual health plans in maternal health. It has also been included in the curriculum in the Gadjah Mada University. The other great breakthrough was the application of Health System Performance Assessment on sub national level. The method was also used to evaluate the impact of the Tsunami and the massive relief and reconstruction effort on health in the affected Province of Aceh. Data from before the disaster was compared with data after. The result was a rather unfavorable finding for the relief inputs. Infant mortality, child mortality did increase and health status declined significantly from 2004 to 2006. For this work I got the support of the old WHO team, Ajay Tandon, Cecilia Vidal and also Chris Murrey, then scattered across Harvard and the World Bank. The product, a book, was appreciated by the government of Indonesia and the scientific community. I hope it also impressed the WHO metrics team . I can’t tell if it is related or not. But a Health System Metrics approach was developed. Again a new name, remember my old wine remark from above. A further methodology, which I was familiar with since my first days with WHO, is the collection and use of data on medically certified cause of death (CoD). One of my former colleagues, Dr A.D. Lopez, had returned to his homeland and is professor in an Institute in Brisbane (Australia). His outstanding expertise in CoD techniques, the proximity to Indonesia and the availability of Australian funds for Indonesia motivated me to collaborate with his Institute. It was possible to raise considerable funds for this activity through Australian Aid. Since then, a population of approximately 2 million is covered by complete reporting of Medically Certified Cause of Death Certificates. The ultimate target is 30 million, so there is still some work ahead.

Peter, with all due respect for statisticians, please give me some arguments in favor of this achievement related to death while I, as a doctor, was concerned with keeping patients alive. As you state the concern of medicine is life and not death. However, we all end up dead. That is not a matter of what went wrong but a natural event in life, like many others, and worth to be studied. Therefore it is extremely important to convince Governments to make more efforts to establish correct Cause of Death data and statistics. The history of public health contains convincing arguments. The origin of vital statistics in the modern sense can be traced to an analysis of the English bills of mortality published by John Graunt in 1662. In the nineteenth century, the industrial revolution resulted in rapid urbanization, overcrowding of cities, and a deterioration of social and living conditions for large sectors of the population. Public health reformers became acutely conscious of the need for general sanitary reform as a means of controlling epidemics of disease. These early sanitarians used the crude death statistics of the time to arouse public awareness of the need for improved sanitation, and in the process they pressed for more precise statistics through effective registration practices and laws. Thus, the history of public health is largely the history of vital registration and statistics. Records of deaths by cause shall continue to be needed for the control of epidemics and the conservation of human life through sanitary reform. During my early years in WHO, the cause of death data was used to identify patterns in the ever increasing incidence of cancer. Countries like Indonesia are going through a socio-economic development and industrialization. The chal- lenges to adapt the health system to the current developments are enormous and it is evident that sound epidemiological data is needed to guide health policy in the right direction.

Tell us about your work during the 2004 Tsunami It was one of the dark chapters of my work. Maybe because there is not much I could really do. It was a catastrophe of unimaginable extent. The response in form of aid and reconstruction was claimed to have been successful. What I saw was that the WHO response was there but the agony of getting things done was enormous. The difficulties in organizing aid suggest that it has never been the role of WHO to be on the forefront of Disaster Relief. Initially WHO advised some relief agencies and the government on priorities. Other organizations just went ahead anyway. We had a significant influx of logistic expertise to manage the huge amounts of donations channeled through WHO. We went in one month from 50 staff to 350 staff.

So, please explain why, how from a “data specialist” you got involved as a relief operator. My role was the organization of a Health System Performance Assessment (HSPA) survey and to monitor and support the information activities of our Aceh offices. Again, in the reconstruction effort District Team Problem Solving method was applied and appreciated. But it was also imperative then to attend all meetings related to Tsunami matters which were practically all matters at that time. It was obvious that we had to be there when something happened. The whole world watched. The top WHO leadership was extremely nervous about ensuring WHO had its share in the news and that they had better be positive. All that is very understandable but when we talk about media circus we do mean circus. To be more explicit, this circus motivated persons from all levels and also Organizations, including WHO, trying to get a better and visible profile by surfing the Tsunami. The news of their success was often fabricated. The suffering of the population is a totally different story. The WR Dr G. Petersen was somewhat sidelined 2 while Tsunami “heroes” became famous on world TV.

2 I think the then WR Dr G. Petersen would be a perfect person to give an overview on that critical event for the country office in Jakarta. However, it would be probably worthwhile to have a review of a greater number of staff which were posted then in Jakarta to come to a balanced review.

Last event, the H5N1, was the Avian doomsday for the so far cordial relations between WHO and the Ministry of Health of Indonesia. The Bird Flu was announced as the coming of the new scourge of humanity, wiping out millions of humans like chickens. And as we just calmed down and sized down after the Tsunami the media circus started again. Being in the forefront on the TV Screens was the thing. This time the disaster was the deterioration of the relation of WHO with the Ministry of Health of Indonesia. This all happened in the last days of my service, while also WR Dr Petersen retired and a new Health Minister was nominated as well as a new Regional Director. It is unimaginable, but we had copyright disputes over virus samples. I am aware that it is difficult to manage emerging infections and to predict their epidemiological future, but a bit of modesty on the part of WHO would be helpful for keeping a good reputation.

Tell us about people that you do remember well Dr Petersen was my last boss and was truly a remarkable WR, but I met and worked with many other remarkable people. Dr A. D. Lopez was a young man when he joined, almost the same day as me. He astonished me how much a demographer can do to influence health policy. Just type ‘Lopez AD Tobacco’ in a search engine. The Web will illustrate that cause of death data and a good demographer can start a serious challenge to unhealthy life styles. Dr S. Sapirie always astonished me about how much a man can be working, remain simple and clear in expression and in his approach to health systems and propose useful solutions. Dr J. Frenk was a great person to listen to and to work with. I am sure he still is inspiring his staff in Mexico as Minister of Health. The regional Director Dr Uton (SEAR) and the Minister of Health of Indonesia Dr Sujudi were Asian Gentlemen who knew how to run big organizations smoothly, to deliver and at the same time avoid any International/ National/Regional controversy. Dr Soeharsono, my ever smiling counterpart from the Ministry of Health in Indonesia, was always helpful and highly appreciated by his countryman and by all of WHO for having been the most knowledgeable person in the area of health surveys in Indonesia. Surveys are the most reliable information in that country.

Your sharp vision of the functioning of WHO is fascinating. Please tell us more. There were many others which were remarkable, not always in a positive way and many have been remarkable how unremarkable one can be. I have never counted but I am sure that it is safe to state that the positive remarkable colleagues and collaborators in the Organization and in countries constitute the large majority of persons I had to work with. The role of the Director General used to be in the domain of health policy and has during my career unfortunately shifted to the position of a top business manager. The Regional Directors and their dependence to regional politics are often perceived as a problem. However that can also be perceived as a solution. The more we have nominated civil servants the more we have to face popular mistrust. The EU Commission and it’s relation to the EU population is a good example for this concept. The complex organization of WHO reflects the complex situation in the World. It could be possible to reorganize, strengthen the Executive Board , reduce WHO HQ dramatically and have regional competence centers. When being part of WHO I had quick and ready solutions for all structural problems. Now that I am not part of it any more it seems to be more difficult to come up with one of those golden bullets. There have always been solutions and re-organizations in the air in WHO. But why changing one piece when the rest is not re-organized? But who will and can do such a gigantic task?

You clearly point out a schism between an “HQ problem” and a solution linked to “work in countries”. Yes, there was increased firing and hiring, especially hiring in HQ as they went from 800 to 2500 staff. In my opinion that was a wrong trend. It has led to shifts of doing one thing and not another in the domain of public health where a broad range of problems is globally present. It has also led to a huge number of HQ staff unwilling to work in countries. Mobility has always been a problem. Some staffs are stuck in a country office for 10 years because HQ staffs avoid the discomfort of some duty stations. Let’s consider the mobility issue. It would surely be detrimental to Directors and Chiefs in HQ as they would most likely loose their staff and probably their position. But would it not be beneficial to the Organization as there are too many of them? During my HQ work I had no major problems with the administration. If something went wrong it was at the Director and Chief level, two positions which like to speak up in the name of WHO and sometimes confuse their own ambitions with those of WHO. The relation with other Organizations comes out very strong at country level. It is usually excellent and respectful. But I would not say that we really work together. That could certainly be improved. Again, here we have a limitation due to the complexity of the UN system and it is difficult to fix one or another part without looking at the whole UN System. I would not dare to say that I have an in depth knowledge of it as a whole.

WHO had also some positive achievement, no? Yes of course, but most of WHO’s worldwide remarkable achievements are from my early days in WHO such as Primary Health Care and Smallpox eradication, during Dr Mahler’s time. These concepts and activities are recognized universally and constitute the backbone of the respect WHO has earned globally. On a whole it was a great experience to work for WHO. I do not regret a minute of it and the good days and the bad days are part of that experience. Being with people from all countries, working in many countries and many languages is exactly what I wanted and what I got.

How much did your travelling life have an impact on your family life? My family in Austria never thought it was a good idea to leave home for such a long time. I guess it is not everyone’s desire to be international. For those who want to be international it is like finding a new family, the international one. It is too soon to retire at 60, like loosing a family and going back to a home which meanwhile is as strange as any other country. Again I am in a different situation than most people here, as they want to stop working and complain about their job. Like me, I suppose most colleagues from WHO, liked the job and would like to work longer. The task was to find something to do. I am happy to still have young daughters, Aquila and Sofia. There I have a meaningful occupation by taking care of them.

Thank you very much Peter for this stimulating exchange.

This document is not a formal publication of the World Health Organization nor of the Association of Former WHO staff. The views expressed by interviewees are solely their responsibility.