The World Health Organization is the leading international agency in health. WHO's reputation reached a peak in the 1970s with the then director-general Halfdan Mahler's advocacy of Health for All by the Year 2000 and the successful worldwide eradication of smallpox. The 1980s and 1990s saw WHO lose much of its authority. Too easily, the blame was put on one man-Mahler's successor, Hiroshi Nakajima. In 1998, Gro Harlem Brundtland, Figure 1 a former Prime Minister of Norway, took office and WHO began a period of major strategic and structural reform. Almost 4 years into her first term as director-general, I visited WHO's headquarters in Geneva to learn about Dr Brundtland's successes and failures. Figure 2 The ground rules of my visit were that I could talk with anybody and attend almost any meeting (budget discussions were excluded). I interviewed Dr Brundtland, executive directors, members of the staff association, and directors and project managers of programmes such as StopTB, Roll Back Malaria, HIV-AIDS, violence prevention, polio eradication, essential drugs and medicines, and sustainable development. At senior levels, WHO is confident and clear about its purpose-in a way that matches Mahler's vision and goes beyond it in results. Brundtland told me that her most important achievements were to have "strengthened the credibility of WHO" and to have "raised the awareness of health on to the political and global development agendas". But there is a troubling schism between the aspirations of its leadership and the realities faced by the organisation on the ground. Rapid change during the past 4 years has reinvigorated WHO's mandate, but poor management has created new tensions that the organisation's leadership seems unwilling to address.
