As Jonathan Quick, Director EDM, leaves WHO he speaks to Monitor Editor, Richard Laing, about his career to date and his plans for the future.
RL: Thank you for meeting with us, I think it is a great opportunity for us to have you review your career in essential medicines, so our readers get to know you in a rather different way. To begin, can you tell us who and what were the major influences in getting you here today, as nobody in essential drugs has come through a conventional career path?
JQ: That's true. There were several influences. On my mother's side of the family, there are several generations of medical people and on my father's side business/management people, and so that sort of laid the foundation. A number of people were important but three come to mind, one was the head of preventive medicine in Rochester, USA. He was a professor who, when I needed to do a thesis for a masters degree and wanted to do it overseas, was wildly supportive and that gave me the early support to get involved in international health. That led me to the second person who is Ron O'Connor, founder and head of Management Sciences for Health. He had the courage or recklessness to send a third-year medical student around the world in 1978 with absolutely no demonstrated research capabilities to look at what was then called basic medicines programmes, in eight countries on four different continents. His willingness to do that was what led to the book Managing Drug Supply* and basically got me hooked into that area. The more recent influence in my transition to WHO was David Nabarro, then in the UK Overseas Development Agency. So it was that string of individual influences. I think the other thing is that as a child I spent a lot of time watching adventure movies set in Africa, the Middle-East and Asia, and when I think back that really developed my interest in the rest of the world.
RL: What meetings or other events do you view as either informative or very significant?
JQ: Back in the late 1980's there was a meeting at Harvard that the founding director of WHO's Essential Drugs Pro-gramme, Ernst Lauridsen, had and I think Lauridsen has had an indirect effect by influencing the people who have worked with me. In terms of meetings that have affected my thinking, there was a big national drugs policy meeting, in Australia in 1995, which was arranged in a very interactive way, and I think it was a bit of a watershed in getting people cross-linked in that region.
RL: Can you talk a little bit more about the countries you visited for Management Sciences for Health, and how that experience got you into essential medicines.
JQ: I had to do a thesis and I looked around for a way to do it overseas. I decided to work with Management Sciences for Health, which had just got a small grant from WHO to look at essential medicines. I had an interest in pharmacology, and had spent a summer working in Washington for Senator Edward Kennedy's health sub-committee and had some contact with the US Food and Drug Administration through that. At that time, January 1978, WHO had recently completed the first Model List of Essential Medicines. I arrived in Boston (MSH headquarters) to start work on the thesis and was given a stack of papers, not even half a metre high, which represented pretty much everything that had been written on essential medicines up to that point - no kind of conceptual framework or idea of what the pieces were. My job for eight months was to plan a trip around the world to look at this and to basically do essential drugs management research. At that point the focus was very much on the nuts and bolts of selection, procurement, distribution and use. Then it was a question of where to go. I ended up choosing Peru which had one of the earliest generics and rational use programmes, going back to the early 1970s, also Guatemala because they had a good management person there, Costa Rica because they had a good programme of social health insurance and Norway, because it was a small country with tough logistics and so very educational in that respect. Tanzania was on the list because they were one of the leaders then on pharmacy education, with pharmacy technician training. The leading policy programme of the 1970s was Sri Lanka so it made sense to visit there and they had done some good work in management. Malaysia had had a strong tradition of pharmacy and good public sector management, so I went there.
In each country I had roughly two weeks to figure out what there was to learn. The last country was Papua New Guinea and again it was one of the unsung successes of essential drugs. They'd had what we would now call an essential drugs pro-gramme back in 1945, and had a lot to teach. People all gave very different pictures of the current state of things and then that actually led to the overall framework which we used for Managing Drug Supply.*
Each country visit was written up but nobody was much interested. WHO was not sure where all this was going to go, so the whole thing slept for two years while I went off to be a family medicine resident.
RL: And then you wrote the first edition of Managing Drug Supply?
JQ: It was really interesting because we basically sat with Ron O'Connor around October 1980 to finish the outline, and by October 1981 had the book done and out to approximately 120 countries. It was the least professional and most efficient book writing experience I have ever had.
RL: You have talked about those eight countries, and since then, you have had the opportunity to visit many others. What are the things that have been really significant for you?
JQ: The thing that struck me then and still strikes me now is how similar the problems are from country to country and how creatively diverse are the responses in the solutions. I think one of the biggest barriers to progress is just not learning from what others have achieved.
The man who made General Electric the biggest company in the world, said that for his first 10 years he fought what he called the NIH reflex - Not Invented Here. People would react against anything that they hadn't discovered themselves. What he said was, take the ideas, plagiarise the ideas, use the ideas, learn from whatever works. And we tried to make Managing Drug Supply an ideas book. The other thing I am struck by, looking back, is if you ask where has there been significant progress and sustainable progress, it's been where there has been both strong political commitment and sound technical support. We can look at Norway in the 1960s, Sri Lanka in 1970s, the Philippines 1980s, South Africa 1990s and Brazil coming into this decade with its AIDS Programme. It's been where those two ingredients (political commitment and technical support) come together. What I find interesting and ironic is that many people from the political culture and the technical culture seem to miss the fact that they need each other to succeed.
RL: What have been your greatest professional challenges?
JQ: By far and away, 1998 was my toughest year. I was still relatively new to WHO and that's when the whole issue of patents and the WTO TRIPS Agreement hit the World Health Assembly. The debate over the Resolution ended on a Friday afternoon with, by all accounts, the worst shouting match anyone had ever seen in the Assembly for 20 years. It set up a year of tough discussions and it happened at a time when WHO had new leadership coming in and it was unclear where it stood. It actually wasn't clear where any of us Directors then stood in terms of our futures. So it was a combination of a high demand, difficult problems, lots of vested interests and lots of uncertainty in terms of both personal and organizational support. And I think that it was technically difficult because there were a mixture of medicines policy issues, legal issues and intellectual property issues, and the content of these issues was totally new. As far as I can figure, it was equally or more contentious and complex in terms of the stakeholders than the initial dynamics when the essential drugs concept was introduced in the late 1970's.
RL. And how do you feel about the way this has all been resolved over the last four or five years?
JQ: I think in terms of clarity at the global level about the flexibilities in the WTO agreements, the opportunities to ensure competition in the pharmaceutical market and to balance innovation and access, that most of the global decisions, like the Doha Declaration on the TRIPS Agreement and Public Health, have gone in the right direction. The recent decision in relation to the so-called Paragraph 6 problem, on the import of medicines under compulsory li-cence by countries that cannot produce, is probably not the best technical decision from a public health point of view but politically the basic messages were right: that these arrangements should apply to all medicines and that countries do have flexibility. Interestingly, the Doha Declaration affirmed nearly all the points WHO tried to make in 1998, and actually confirmed that we were correct in our analysis. So, I think globally things have gone well. Within countries, things are not going well. All of the rights that people agree countries have globally are not being implemented when you actually look country by country, so that is worrying.
I think the other major challenge was when Dr Brundtland came in as Director-General and decided to merge the former DAP, the public health and essential drugs programme, with the former DMP, the normative quality and safety programme. There were tensions, and we were supposed to figure out how to make that merger work. That was a challenge and I have certainly learned a lot from it. The results of that merger have been hugely beneficial for countries, even though there are some things that still need to be worked through.
RL: That brings us to the next question. What do you think are your major achievements as Director of EDM, would managing that merger be one of them?
JQ: I think part of the merging process, and one of the things I am happiest about, was to step back and to define a single WHO Medicines Strategy** that was sensible for countries on the ground, and that was in the end endorsed by all WHO Member States. That really provides a framework for all of WHO's medicines work, with the core aims of affordability, accessibility, quality and safety, and rational use. To add to that, is a practical monitoring programme to assess WHO performance in country progress. So each of our aims is underpinned by some specific and measurable progress indicators. People don't want to hear how many meetings WHO has held, they want to know what difference it has made - have prices gone down? Has availability gone up? Are fewer unnecessary injections being given? Is generic substitution possible? Is drug promotion being monitored? Are safety mechanisms in place? Is quality improving? I think a third area is traditional medicine, where we have been doing a lot of individual activities but we haven't had an overall strategy. What we tried to do is bridge the gap between the sceptics who think that none of this works and the enthusiasts who think that it all works and it is all safe, and in reality it is somewhere in between. We published a strategy about a year ago which was very well received and we had a very good debate at this year's World Health Assembly about its implementation.
RL: Even before you became Director you were involved in writing a number of publications, on finance and public/private roles, for example, yet there seems to be a continual demand for those sorts of review and analytical publications. I would have thought those would have been on your list of achievements?
JQ: I haven't got there yet. On the whole, I would say we had as a programme been so country focused that we were putting so much energy into just helping individual countries, which is absolutely a priority, but we weren't really thinking about where things were going. I think it's necessary to try to strike the balance between knowledge creation and knowledge implementation. So yes, I think the work on the public/private issues was important, and I have been supporting people in the department who are modernising the approach to the Model List of Essential Medicines and some of the things on pricing - getting people to think about where there are major gaps and addressing those in a practical way.
RL: Are there any other things on your list?
JQ: I'm happy to see the evolution of the Global Medicines Council - the four headquarters-based team leaders and six regional advisers on medicines issues. Eight years ago, they had only met twice in the preceding 15 years, now we meet at least once a year face to face and then we meet quarterly by video. I think that group has helped us to achieve much more coherence in the way that we approach things. I also think that we were focused straight towards countries and not across departments within WHO. What we have tried to do is to become an internal consultant. We have joint staffing arrangements with AIDS and malaria, and at one point TB. I think that kind of bridging has been important, plus bridging with all of the UN agencies. Eight years ago, there was a lot of tension among UN agencies. Now there is still tension occasionally. But we can get on the phone and debate it through.
RL: Disappointments? What didn't you achieve that you had hoped for?
JQ: I think I have learned a lot, certainly looking back, knowing what I know now, there are things I would have done differently. But I don't have any regrets per se. I think faster implementation would have been good. Implementation would have been helped by being more decisive sooner on some of the tough issues. You always want more financial stability in a programme, so in the last two years there has been much more attention to that. We were slow to understand the importance of good public communications. It's really only been the last two years that we have had a regular communications initiative and we have tried to actively get to the public and professional media.
RL: With the changes in the last few years related to AIDS/TB/malaria, how do you think the programme could have adapted to the implications of the tremendous interest and funding available for those diseases, while still balancing the ongoing needs of countries and programmes?
JQ: I think in most respects, certainly in the AIDS area, if you look at most of the key pieces that ought to have come from a medicines group, most of those were started in the last three years: the process of selection and getting the right antiretrovirals, starting to track prices and sources, looking at quality, and regular prequalification lists. The first level framework and support structures are in place, so we are now moving to look at how to get the drugs distributed in countries. We have actually looked ahead to see the key things needing to be in place and what was missing. What is now coming with the 3 by 5 strategy is a unifying framework that bridges the medicines area with the financing, with the prevention and health systems programme - all that was missing and now that's coming together. What we are seeing now is the need for a kind of new medicines coordination group that looks across all of the components that links together the development of the public health data and evidence. A committee that says this is what we ought to be using, with the identification of producers, with the development of quality standards, with the development of markets and a buyers group. For some of the diseases we have most of those pieces but for others we haven't and we are catching up.
RL: What about advice for your successor, whoever that person might be?
JQ: The first thing is to keep the basic mission in the centre of attention. Setting priorities is probably the single hardest thing. We have a clear mission, which is saving lives and reducing suffering by being sure that people have the medicines they need, when they need them, of good quality and that the medicines are used well. People can disagree with your specific policies and actions but if this mission is in the centre of things it's hard to disagree with your direction. I think the second thing is to really trust the team of people who are working here. There is a world class group of essential medicines staff at headquarters, in each of the regions and in many countries, so set the direction, justify priorities and then support, support, support. The third thing is to do the analysis. When tough issues come up, avoid political correctness reflexes, avoid rote reactions, avoid stereotyping - but don't avoid the core issues. Whenever we have made it through tough issues like the revision of our approach to the Model List of Essential Medicines, prequalification of antiretrovirals, WTO agreements issues, it is because of good analysis. What are the issues? What's at stake? What are the options? What makes sense from a public health point of view? If you ground the debate in good analysis you have hope of getting sensible, defensible outcomes. I think those are really the main things.
RL: What do you think the priorities over the next five to 10 years should be, if we were looking back down the road in 2015, what would be the big differences?
JQ: Human resources, numbers of people and the sort of training. The greatest perversity of globalization is that low-income countries are actively subsidising high-income countries with pharmacists, with nurses and with medical doctors. Developing countries are losing their medical and pharmacy leadership. So I think we have to look pragmatically and realistically and take a practical approach on human resources. The second is medicines financing. The single biggest problem in access to medicines is financial - unfair financing, the fact that in poor countries it is poor households that pay the biggest bill for medicines. Unfair financing can be addressed in a variety of ways through public financing, insurers, employers and through good use of international assistance. Also the financing lever is probably the most effective lever in fixing some of the other problems in the system, in promoting rational drug use policies and in ensuring a reliable supply system. The third thing is realistic thinking about management systems that really work - supply, regulation and other core functions. Do not assume that a particular function should be done by the public sector, by civil society or the private sector. We need to say: to get this job done, who performs best and is most competent, so that in the end we have management systems that actually produce results for people.
The fourth area we have already talked about, and that is the WTO and TRIPS. In terms of implementation of sensible pro-health policies in countries, that's not happening anywhere near to the extent it should. If we get it wrong now, it's not just wrong for us, but for our children, and our children's children, because the precedents get set the wrong way. It is now generally acknowledged that overly strong intellectual property patents hurt access to medicines in low-income countries. But we don't yet have a paradigm that really works to balance access and the necessity to develop new needed medicines. The paradigm that works for Europe and North America cannot just be extended as it is to countries with 1/10th or 1/200th of the per-capita income. It simply won't work. We still don't have quite the right paradigm or set of solutions.
I think the last priority is on the ethical dimension: corruption and just bad ethical behaviour. Recent experiences in the investment world of developed countries tell us that ethical lapses are universal and there is really no country or part of the world that has a monopoly on the size or frequency of these lapses. So I think we just have to say that this is a universal problem. It is a problem that is in pharmaceutical procurement, but it is a problem that is equal or greater in pharmaceutical promotion. I'm appalled that some companies are just discovering ethical principles for drug promotion that were set out 15 years ago. We need to realise that we can have plenty of money and pretty good management in principle, but if there isn't a real commitment on all sides to ethical practice, systems just won't work.
RL: I'm sure you have smart young people ask for advice on following in your professional footsteps and working in essential medicines, and because it is not a standard career path, it is quite a difficult question.
JQ: It's true. One thing I would say is build in a variety of training experiences. I was an undergraduate major in sociology and psychology. During medical school I took a two-year MPH and I did all my electives in the School of Management and the School of Education. Along with that goes diversity in field experiences. I actually found it was very useful to have spent several years in clinical practice as a family physician, to work out of an international health organization for five years doing short-term work in several different countries, and then to have lived and worked in three other countries. The other thing is not being afraid to take informed risks. If there is anything I have learned in the last few years it is to take informed, but not reckless, risks. For example, the prequalifi-cation project, that was a bit of a risk. We didn't know if it would work. I wish I could have said I imagined all of the spin-off benefits that it has achieved - improving local production, improving the awareness of regulators on good manufacturing practices. But I didn't. Basically we took a risk.
RL: One thing you have always done though is write about your observations in a pretty systematic way. Do you think that's been an important part of your development?
JQ: I think people don't spend enough time thinking. For me, writing is actually a way of thinking and it has been extremely useful.
RL: As an author who has written widely on stress in the workplace, what techniques do you use to stay calm in a high pressure environment like this?
JQ: One of them is trying to run in the mornings as often as I can. It burns off frustrations, reduces anxiety and helps in thinking through tough problems. Time spent on exercising is almost always repaid by better concentration and productivity. The second thing, is to focus positively on the future. Look at things we can change and don't be looking negatively at the past. Deal with the world as it really is and not the world as we would wish it to be. I suppose the last thing I have learned from hard experience is to keep a good balance between work and family and friends, and I consider myself a recovering workaholic.
RL: So we have talked abut how you relax, what about reading, do you have time to read other, non technical, materials?
JQ: Yes, I try to read periodicals from both ends of the political spectrum, so the Economist and the New Internationalist are two of my favourites. I like reading biographies, management books, books from contemporary Christian writers.
RL: And your goals for the future, after WHO?
JQ: Clearly one goal is to support my wife and three daughters in being as happy and successful as they can be. I am going on to head Management Sciences for Health. MSH deals with the building blocks of health care: financing, people and medicines, and the management glue that make health systems work. MSH has a long history of helping countries to make practical improvements in their health systems. I hope to help MSH build on this success to have an even greater impact in the future. In my 70's maybe I'll spend more time drumming. I still play the drums.
RL: Have any of your family followed in your footsteps professionally?
JQ: I'm a little bit young for them to have followed yet, but I have one daughter who is interested in becoming a paediatrician. My grandfather was a paediatrician who at age 60 went through psychoanalysis and became a child psychiatrist. He finally retired at 85 and died at 105. So I suppose I like to think I might be close to his trajectory.
RL: Last question - If you hadn't followed this career path, what do you think you'd have liked to have done?
JQ: Good question. In high school I thought I'd either want to become a chemistry professor or run a pizzeria, because I used to make pizza on Sundays. I think if I was to do something different, it might be journalism or broadcast media, something that brings ideas together, or just more time writing, but I have been really happy with this mix of medicine and management.
RL: Thank you.
Dr Jonathan Quick has worked in the Department of Essential Drugs and Medicines Policy for the last nine years, six of these as Director. He leaves at the end of January 2004 to become Chief Executive Officer of Management Sciences for Health.
* Quick JD ed. Managing drug supply. Boston: Management Sciences for Health; 1981.
** WHO medicines strategy. Framework for action in essential drugs and medicines policy 2000 - 2003. Geneva: World Health Organization; 2000. WHO/EDM/2000.1.