I mention the World Psychiatric Association (WPA) mainly to make some wider point about the close linkage between pharmaceutical companies and the highest spheres of influence, notably the World Health Organisation (WHO). Very simply, the model I have in mind involves companies pumping money into the WPA and its constituent organisations, and the WPA pumping influence into WHO.

The WPA co-ordinates international activity among 110 national psychiatric societies (eg the American Psychiatric Association, Royal College of Psychiatrists) 'representing more than 140,000 psychiatrists worldwide'. Of these, 40,000 are members of the APA; inevitably, US influence in the WPA is strong.

The WPA Secretariat, based in New York, runs off a small annual budget ($354,000 in 1998), a trivial sum in relation to the activities organised in the Association's name. Thus, over 13,000 participants attended its 10^th World Congress of Psychiatry in Madrid (1997), and the event produced a surplus of $87,000, over one-quarter of the WPA income in that year. The WPA is also a major publisher in the field, runs regular conferences and meetings, operates several Standing Committees and includes a 'scientific arm' comprising 48 different sections, whose main task is to develop ideas and standards relating to basic issues in psychiatry. These include several of great commercial significance, including disease definition and diagnosis.

Neither the WPA, nor its national member organisations, publish annual accounts indicating the extent and value of pharmaceutical industry funding, but it is surely substantial. However, some published information is available, including the WPA Guidelines for external sponsorship of its activities. These basically say that support should be in line with the organisation's objectives and ethical principles, subject to audit, and disclosable to WPA members. WPA lists the types of contributions it may receive as follows:

A. Contributions to WPA organised or sponsored scientific meetings

(i) donation to a specific item of the meeting's budget (eg the printing of the abstract book)

(ii) educational grant for a symposium

(iii) contribution for the organisation of a fellowship or scholarship program

(iv) contribution concerning the organisation of a satellite meeting or another specific event

(v) sponsoring the attendance of speakers and/or participants

(vi) donation for a specific social event (eg welcome reception)

(vii) donations for general managerial expenses related to the holding of a WPA meeting

B.  Contribution to other WPA activities

1. Scientific and educational contributions

(i) sponsoring of a WPA educational programme

(ii) sponsoring of a WPA task force

(iii) support for the activities of WPA standing committees

(iv) a donation to a WPA publication

(v) support for the activities of WPA Zonal representatives

(vi) support for the activities of WPA sections

(vii) contributions to an Award

(viii) contributions for other specific WPA activities

2. Donations supporting WPA work in general

C. Commercial arrangements

Pharmaceutical or other organisations may also enter into commercial arrangements with the companies providing services to WPA eg rent space for exhibition during a scientific meeting, advertise in WPA publications or in other WPA products (eg audio or video tapes, slide kits)

With such a long shopping list, company support could be expected to run at least into $ tens of millions a year. Overall levels of sponsorship are not known, but funding for individual programmes is generally acknowledged on an ad hoc basis. Thus, Eli Lilly has recently been credited for sponsorship of a special meeting of presidents of psychiatric societies, in Singapore "to examine the current state and prospects of psychiatry in Asia"; as well as three major educational programmes - on the Diagnosis and treatment of depression, Fighting Stigma and its consequences, and Core Curriculum for the Undergraduate Teaching of Psychiatry.

Meanwhile, companies also contribute to numerous educational and promotional programmes organised by national societies (eg the Defeat Depression Campaign) - and of course provide for selected individuals to participate in them. It is not clear how much funding is involved, both above and below the line, but it seems safe to assume that many national psychiatric societies would wither without it. Here are two examples I used at a recent HAI meeting on sponsorship by the pharmaceutical industry. Both record decisions taken at the July 1998 meeting of the Board of the American Psychiatric Association (APA): 

9.41 Proposed fee structure for Industry Supported Symposia

The Board voted to approve the proposed fee structure for 40 industry sponsored symposia starting with the 1999 Annual Meeting, which calls for increasing the current fee structure for a 3 hour session from $35,000 to $45,000.

14.A Patient Newsletter for APA members

The Board voted to accept the proposal of Smith Kline Beecham to enable APA to offer APA members an opportunity to create their own patient-oriented newsletter as an APA member benefit at no cost to the Association.

WPA & WHO

The President of the World Psychiatric Association (WPA) is Dr Norman Sartorius, former head of the WHO Division of Mental Health and Prevention of Substance Abuse, and a leading name in depression. His predecessor as WPA president was Dr J.A. Costa e Silva, who later became Director of the same WHO Division. Dr Costa e Silva recently indicated that he stepped down from all WPA commitments when he took over at WHO. However, he is identified on the WPA letterhead as a member of its Council and (according to his CV on the WHO website) as task force chairman for 14 international educational programmes at the WPA. A "formal collaborative agreement" exists between the WHO and WPA, and the two organisations work jointly on numerous programmes and are signatories to other accords.

Notable among WHO/WPA joint ventures has been the programme on International Classification of Diseases. This is of critical importance not only in promoting the ever wider use of antidepressants, but also in defining 'dependence' in such a way as to make iatrogenic dependence (of the benzodiazepine variety) a thing of the past. I have argued elsewhere this was an improper thing to do, but of course it was all very properly done.

One way and another, the relationship between the WPA and the WHO (MHD) has been very close indeed:

"There is regular exchange of information (with the WPA) and attendance at meetings involving not only headquarters but also WHO regional offices. Members of the Speciality Sections of the Association (WPA) serve on WHO expert advisory panels, and WHO staff participate in WPA sections, such as that on education in psychiatry, epidemiology and community psychiatry, and on drug dependence. Examples of current collaboration are input to the International Classification of Diseases, 10^th revision. WHO participates in the World Congress of Psychiatry and related working groups" (http://www.who.int/ina-ngo/ngo/ngo181.htm)

"The appearance of the ICD-10 Classification of Mental and Behavioural Disorders has been an event of vast importance for Psychiatry… The World Psychiatric Association, the World Health Organisation as well as other educational institutions and Centers have carried out presentations and seminars concerning the role of ICD-10 in different countries with great success…The files (that have been developed in the basis of experience gained in such a process) have been produced by the World Psychiatric Association and the WHO Division of Mental Health and Prevention of Substance Abuse as a courtesy to the participants of the 10^th World Congress of Psychiatry". (http://www.who.int/msa/mnh/ems/icd10/icd10ekit/intro.htm)

"At the initiative of the World Psychiatric Association, the World Health Organisation (WHO) has published a report entitled 'Rational Use of Benzodiazepines' (WHO/PSA/96.11) … a concise and professional summary … (that) lies closer to clinical reality than current Swedish recommendations. For example the report recommends that benzodiazepines with a long elimination time be used for long-term treatment (more than 6 months). The report also provides evidence that the actual addiction rate is about 1% of all treated cases" (http://www.psykmott-ntorg.a.se/benzoart.html)

Avoiding Conflicts

The potential for conflicts of interest goes deeper even than company sponsorship of sensitive programmes. Thus, when the new administration took over at WHO, it seems the WPA began concerted lobbying - creating an extraordinary situation, in which the WHO Director-General was being lobbied by an organisation in which a WHO head of division played a prominent part:

WHO'S REORGANIZATION AND THE RE-EMERGENCE OF MENTAL HEALTH On May 13, 1998, at her inaugural speech as the new Director General of the World Health Organization, Dr. Gro Harlem Brundtland spoke of the importance of mental health and the crucial value of NGO's for the organization. However, during the weeks that followed, news coming from Geneva suggested that a streamlined WHO would not include any distinctive mental health structure. Perceiving this as a grave threat to mental health programs everywhere (as governments usually follow WHO for the organization of their own health services), our mental health community reacted at once. An unprecedented number of letters of concern reached Dr. Brundtland's office, many of them from WPA's s leadership and various components… At press time, we have learned that mental health has not only been preserved, but has emerged strengthened … While the WHO reorganization process has not been completed yet, it has emerged that Professor Jorge Alberto Costa e Silva, past Medical Dean and Rector of the State University of Rio de Janeiro and Past-President of WPA, will continue as the leader of WHO's Division of Mental Health.

It was all this that prompted Social Audit (18 November 1998) to write to Dr Costa e Silva, to ask how much WHO relied on WHA for funding: "Has any assessment been made of the financial value of the WPA's contribution to your Division …?". The answer, "there has been no financial contribution from WPA to WHO", rather misses the point - that no money need change hands for company influence to be profound. The potential (and incentive) for corporate input is evident in the attached Workplan and timetable, 1996-1999 from the memorandum of collaboration between the WPA and WHO.

Dr Costa e Silva has now stepped down from his post as Director of the WHO Mental Health Division (and has recently been nominated as a Distinguished Fellow of the APA). Meanwhile, the new administration, under Dr Brundtland, has made clear its determination that WHO should be, and be seen to be, above suspicion of conflict of interest - but this is clearly a huge task, and they have far to go. A requirement for declaration of personal interests by senior WHO staff was first introduced only in 1998, the organisation's 50^th anniversary year.

Finally, I should disclose some potential conflict of interest myself - having attended several meetings organised jointly by WHO and another of these international medical organisations with skeleton secretariats and very fleshy budgets. There are several that have 'special relationships' with WHO, including the "Council for International Organizations of Medical Sciences". CIOMS has, notionally, an annual budget of $270,000, but raises funds from companies far in excess of this. Invitations to WHO/CIOMS meetings come with offers of free international travel and none too modest accommodation. On the last occasion I went, in late 1997 (before I had ever heard of the WPA), I felt obliged to withdraw early from the meeting and pay my own way. There were some good people there, yet the whole thing felt distinctly wrong.

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