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GENEVA — In late May by secret paper ballot, all 194 member states of the World Health Assembly that have paid their dues will cast their votes for one of three final candidates in the first-ever election of the planet’s top doctor: the director-general of the World Health Organization.
The candidates are Tedros Adhanom Ghebreyesus, 52, a former government minister of Ethiopia with a Ph.D. in community health, who goes by his first name; Dr. Sania Nishtar, 54, a cardiologist from Pakistan; and Dr. David Nabarro, 67, a medical doctor and official of the UN, from Britain.
As the eighth head of the WHO, the victor on May 23 will be faced with rehabilitating the agency’s image, which was damaged over its delayed response to the Ebola epidemic in West Africa in 2014. He or she will have to take the reins of a reform initiated by Dr. Margaret Chan, the outgoing director-general, who is Chinese; lead a Balkanized structure of six semiautonomous regional and 150 country offices; and reinspire morale among some 7,000 staff members, whether at their desks on the bucolic campus for humanitarian headquarters here in Switzerland or braving conflict zones like Yemen to vaccinate hundreds of thousands of vulnerable children.
Moreover, the WHO will have to do much more with much less if President Trump’s plans to cut US aid to international organizations gets through Congress, including a new one to merge USAID into the State Department. The US is the top donor to the WHO, with $747 million committed as of December 2016. Britain — WHO’s third-top donor — has also indicated it may reduce funding unless the WHO adapts more stringent reforms. The Bill & Melinda Gates Foundation is the second-largest donor to the agency, with $629 million at the end of 2016.
Despite the three candidates’ many promises, they face a grim reality. The current agency budget is already $300 million short of full financing. And the WHO is in danger of losing its leadership role in sectors like emergency response and health metrics, a system developed at the WHO in the 1990s that has moved to the University of Seattle in Washington, with financing by the Gates Foundation.
The WHO must respond to more crises around the world while shoring up ill-equipped national health systems and retaining its power to convene, inform and persuade disparate cultures of everything from stopping smoking to destigmatizing depression. The WHO is also leading a campaign to halve medication-related errors by 2022.
Tedros, Dr. Nishtar and Dr. Nabarro all claim to be undaunted by prospects of what the American foreign-policy and global health expert Laurie Garrett calls a “hideous job.”
The new director-general will have no time to get settled before confronting what the UN is labeling the worst humanitarian crisis in its history: the anticipation of major outbreaks of disease along with a famine and drought looming from northern Nigeria to Yemen that is expected to sweep through the Horn of Africa.
As a WHO spokesman, Christian Lindmeier, said, “2017 will bring the biggest challenges, and we’re in the middle of it.”
And there are other crises in the making:
- The third major yellow-fever outbreak in two years is hitting Brazil and parts of Africa, threatening urban areas. “We haven’t seen an urbanized yellow-fever epidemic ever,” said Garrett, a senior fellow for global health at the Council on Foreign Relations in New York. Because of a vaccine shortage, these critical areas are being inoculated with diluted drugs.
- In China, pigs have been piling up in rivers killed by the H7N9 bird flu virus, which became a pandemic that the WHO helped to quell eight years ago. Late last year, a new strain began jumping to humans; in 2017 so far, more people have died than the cumulative numbers of previous years. “We’re facing the largest pandemic threat in 100 years,” Guan Yi, a Hong Kong University disease expert, told Science magazine in February.
- In the next decade, a pathogen designed on a computer screen by terrorists could kill as many as 30 million people within a year, Bill Gates told a security forum in January. “Governments must prepare for these epidemics the same way we prepare for war.”
The question of just how much power and discretion the director-general has over all these potential crises and developments inevitably arises: 80 percent of the WHO budget comes from voluntary contributions, many of them earmarked for projects predetermined by a handful of large donors working with WHO teams. Only 25 percent of the WHO staff work in Geneva and report directly to the director-general. Of the $4.4 billion budget, the director-general “has a $1.5 billion pot to disburse,” said Gaudenz Silberschmidt, the WHO director of partnerships and nonstate actors (as in donors, in international-community parlance.)
Campaigning for the job
The election in May has all the trappings of a global Oscar night and seems to be taking its cues from the 2106 campaign for the UN secretary-general, during which candidates presented their platforms in public venues — including a debate held by Al Jazeera at the UN — and took to Twitter and elsewhere on the Internet. The open process attracted global public audiences in what had been a closeted ritual for an elite club of nations for decades. Ultimately, António Guterres, a former head of the UN refugee agency and prime minister of Portugal, was selected by the UN Security Council in a private vote.
The WHO says it started planning a more democratic exercise years before the UN secretary-general selection process. Until this year, the WHO leader was selected by its 34-member executive board. In January, the board winnowed a slate of six names, nominated by member states to five and then three.
In early April, WHO staff members, playing the roles of member state health ministers, held a dry run in the World Health Assembly hall. That is the closest they will get to the balloting process in May, when each minister will deliver a paper ballot — with no country identification — to one of six designated ballot takers. No WHO staff members will even see the ballots or be allowed in the room.
The first round needs to deliver a two-thirds majority for a candidate to win; otherwise, the voting goes to a second round in which countries must have a Plan B — no time to schmooze between rounds — then a third and possibly fourth round. Voting in secret may protect the ballot, but some WHO observers think the process precludes a much-needed open dialogue about issues and the candidates.
If there is any horse trading happening, it will surely take place during the May 22-31 meeting of the World Health Assembly here in Geneva, as in addition to electing the director-general, member states are negotiating which issues they will take to the UN General Assembly at its annual opening session in New York in September. The World Health Assembly is the first major meeting for international organizations in the lead-up to the session in New York, so alliances will be set in Switzerland.
As for the election, since every vote counts, the three finalists are doing a lot of meeting, greeting and globe hopping. If you follow their travels to detect a pattern, here is what you’ll find: Africa has largely been ignored, as the 54 African Union countries have reportedly committed to Tedros, although Dr. Nabarro was recently in South Africa. Island nations in the Caribbean and the Pacific must be befuddled at all the visions for health being offered to them by the touring candidates.
Tedros was recently in the Cook Islands, Cuba, Brazil and Thailand. Dr. Nabarro stopped in eight Latin America countries recently, as well as in Kazakhstan, Qatar, Indonesia, Japan and South Korea.
Dr. Nishtar has been visiting hospitals and clinics in Jamaica, Barbados, Chile, Argentina, Malta and elsewhere, stressing such priorities as tackling noncommunicable diseases.
The three candidates are campaigning as if the world depended on it. Two have hired public-relations firms, with Dr. Nishtar saying she hasn’t. All three tweet several times a day (see #nextdg) and have blogs, videos and websites. Each candidate has posted his or her campaign funders online, all of which are their governments. Considering the woes at the WHO, the candidates seem long on promises and short on confronting some of the most existential issues before the agency.
If Tedros, Ethiopia’s former health and foreign minister, wins, he will be the first African to lead the WHO. Tedros has also chaired boards of the Global Fund to Fight AIDS, TB and Malaria; Unaids; and Roll Back Malaria. Although members of the Ethiopian diaspora have protested outside the WHO headquarters and tweet regularly about human-rights abuses by his governing party, TPLF (Tigrayan People’s Liberation Front), a snap poll by UN diplomats conducted in early April had him winning the first round. (Ethiopia is currently an elected member of the UN Security Council and is the largest troop-contributing country to UN peacekeeping.)
Tedros says he got the most votes when the World Health Assembly executive board voted in the three finalists.
Dr. David Nabarro has the most relevant UN background, having led campaigns against H1N1 and Ebola for both the WHO and the UN. He is now the UN special adviser on the 2030 Agenda for Sustainable Development and Climate Change. Dr. Nabarro has the visible and vocal support of his government, Britain, a permanent member of the Security Council, and the slickest public-relations campaign of the three. Some inside the WHO feel he could continue to direct the reforms initiated by Dr. Chan without a steep learning curve.
Dr. Nishtar, a Pakistani cardiologist, is considered the civil-society candidate. She established the first federal ministry of health in Pakistan; founded Heartfile, a health care reform think tank; and chairs a WHO commission on ending childhood obesity. She talks about WHO reforms with the critical eye of an outsider who knows firsthand what stakeholders and beneficiaries expect of the organization.
The money situation
While nerves may be frayed at the WHO about the prospect of funding cuts, staff members in Geneva have been there before. Stacks of containers stand empty under a wing of the headquarters building in Geneva. An empty fountain pool in a courtyard was once filled with temporary offices when the organization was responding to an epidemic. A thousand staff members were laid off after the 2008 global financial crisis.
Both the United States and Britain have indicated plans to cut back on foreign aid, but the damage to the WHO is not yet known. “Funding for 2018-9 looks worrying,” said a WHO presentation.
Britain, having committed $412 million as of December 2016, has reportedly threatened cuts unless bigger reforms are made. At the same time, the Foreign Office is promoting Dr. Nabarro to hold the job. But a British health-department spokesperson would say only that the country “is supporting an increase to assessed contributions to WHO on this occasion in recognition of the significant changes we have called on WHO to undertake, particularly around health emergencies. This support comes with the guarantee that the UK will continue to scrutinize all money paid to WHO to ensure value for the money for our tax payers and the global community.”
The White House budget blueprint of March 2017, while proposing to cut almost 30 percent from USAID, specifically exempted GAVI, the Vaccine Alliance — the fourth-largest voluntary contributor to WHO — and the Global Fund, both heavily supported by the Gates Foundation. GAVI was started in 2000 with $750 million from the foundation. A partnership between philanthropy and the pharmaceutical industry, GAVI buys large batches of drugs for poor countries.
Silberschmidt, the WHO director of partnerships and nonstate actors, sounded guardedly confident that US funding would remain intact because of the administration’s interest in global health security, even more so under Trump, a self-described germaphobe whose “America First” budget proposal has been dubbed the “national security budget” because of its obsession with enemies. (The budget status has been delayed suddenly as the US must raise its deficit ceiling to keep the government going.)
American security priorities are not incompatible with how the administration views the value of WHO.
“Of 1,000 crises we’ve responded to, you have heard of two,” Silberschmidt said, implying that Washington has been paying attention to the WHO’s work. Earlier this year, Dr. Chan met with advisers to the US National Security Council, who signaled support for WHO’s work in global health security.
A US State Department official wrote to PassBlue that the US “values the WHO’s leadership role in advancing global efforts to detect public health threats early, especially outbreaks of infectious disease with the potential to spread beyond borders and to respond to them rapidly to ensure they are contained at their source.
“The next Director-General must set clear priorities, starting with global health security, and make the Organization more efficient and nimble, especially in carrying out its normative work.”
While more than half the US contribution comes from the USAID and Centers for Disease Control and Prevention (which also face big cuts under Trump), the rest comes from 13 different agencies, including the Department of Defense.
This level of access — to top security and defense officials, rather than just health ministries — “has been great for public health,” said Katherine Deland, the chief of staff for WHO’s Ebola response.
Médecins sans Frontières (or Doctors Without Borders), a key partner of WHO, is concerned that the organization is devoting too much of its resources to global health security.
“It’s a new trend for donor countries to stress security for their own population,” Rohit Malpani, the director of policy and analysis, said in an interview. “Global health becomes prevention in terms of outbreak response, which is about creating security for higher income countries.”
But the WHO’s 2018-19 budget proposal says “universal health coverage remains at the center of WHO’s priorities,” an indication that rank-and-file WHO member states want help at home. The funding imbalance and priority disconnect has created a “lopsided agenda and a democracy deficit,” Deland said.
Recent reforms begun by Dr. Chan are trying to address the huge imbalance between voluntary and assessed contributions and the agency’s reliance on a few big donors. As of last year, all financial contributions must be plotted into the WHO budget to be approved by the World Health Assembly. Before, only the core budget went to the Assembly for approval.
“We have a smart and clever way of dealing with the 80 percent voluntary contributions,” Silberschmidt said. “But we are bad at communicating about it.”
The WHO initiated a biennial dialogue with donors to improve the alignment of its health objectives. Recently, when Germany increased its voluntary contribution, it indicated the gift should be used where the WHO most needed it.
The six program areas of the agency now have deposit ceilings, so no one category can dominate funding. Still, some areas are seriously underfinanced, particularly noncontagious disease. HIV/AIDS is neglected, too, and the contingency fund set up to respond more quickly to crises after Ebola has received only $30 million of its $100 million target.
Emergency has become a mantra at the WHO in Geneva, and Silberschmidt said the ability of the agency to respond has improved, noting: “Ebola took four months from the first appeal to get the money. Now we have two or three incidents where the money (arrived) within 24 hours to be dispersed. Now we just need the mechanism to reload the contingency fund.”
Although all three candidates have put crisis response at the top of their priorities, the WHO has lost ground as the first-responder globally. Last year, the World Bank moved into the humanitarian crisis field as an even bigger player when it launched its Pandemic Emergency Facility, a $500 million insurance fund designed to release money quickly to curb pandemics spreading to two or more countries. The fund immediately received $50 million from Japan.
Whether the World Bank fund circumvents or competes with the WHO, officials from both institutions contend that cooperation is tight: the World Bank is exploiting its access to the private sector and insurance markets, while the WHO’s data collection will be critical to determining the trigger that springs cash in a crisis.
Dr. Chan has made headway toward the goal of universal health care, and Malpani of Médecins sans Frontières praised her for building consensus around the need for all communities to have access to medication at affordable prices.
Other experts in the global health world are far less sanguine about the pressures on the WHO.
Pushback and politics
“The real challenge will be the wave of regressively conservative politics not just in the US but in other places and among WHO donors in particular,” said Joanne Csete, a professor of clinical population and family health at Columbia University in New York.
“There will be pushback on anything related to reproductive health, migrant health, reproductive rights. . . . There will be enormous pressure for privatization of health services and promotion of big pharma and big food, big soda. . . . All these multinational companies will have newfound status. There will be pushback on climate change-related issues. The new DG [director-general] needs to be somebody who has the courage to risk his or her career to stand up to these forces.”
Several nongovernmental organizations also protest the WHO’s reliance on Bill and Melinda Gates, whose foundation trust has invested in some of the very companies they say cause bad health — such as Coca-Cola — as well as the penchant of the WHO and its partners toward vaccines as a panacea. While vaccines have saved millions of lives, concerns linger over the high price and erratic availability of vaccines and the risky research and development practices by drug companies in poor populations.
In April, the French TV channel ARTE ran a documentary blasting WHO as being “in the grip of the lobbyists.” Among the examples it cited were the WHO’s collaboration with pesticide and depleted-uranium manufacturers and the Gates Foundation.
But it appears that in an era of tight public money, that horse has already left the barn. The three candidates acknowledge the critical need for “nonstate actors.” At a roundtable in Geneva in March, Tedros, who frequently exhorted the WHO to take the “moral high ground” in such relationships, said that a code of conduct should guide work with the private sector, particularly on pharmaceutical costs and prices.
Dr. Nishtar noted at the forum that the Sustainable Development Goals gave organizations a specific mandate to engage with corporate and philanthropic actors but “with firewalls protecting the normative functions.”
Dr. Nabarro noted “our responsibility to make sure no opportunity is lost to help suffering people” and to seek opportunities through partnerships, such as campaigns that beat malaria. He said the food industry was shifting to more nutritious products, indicating private-sector initiatives could be good for women’s and children’s health. “If we get the principle right, this has to be the way to go.”
Persuading donors — governments, philanthropies or corporations — to give “nonearmarked” money will be part of the director-general’s most critical skill.
Dr. Nabarro talks about his fund-raising prowess as an important strength. But his own profiles don’t mention his most recent UN post, that of UN special envoy on Haiti and cholera. In March, The New York Times blasted the pathetic response by donors to the epidemic brought by UN peacekeepers that killed thousands of Haitians and continues to do so.
Asked by PassBlue why his Haiti role was absent from his biography, Dr. Nabarro said that the job had been one of 20 tasks assigned to him as the special envoy for the sustainable development goals; he added that much was accomplished and donations continue to come in for the Haiti cholera response. But the UN website on the project showed only $2.7 million had been raised by mid-April, toward a $400 million target.
Dr. Nishtar has outlined a “new resource mobilization strategy that will diversify the donor base and prioritize assessed rather than voluntary contributions,” possibly adding a levy to donations for the core budget.
In Ethiopia as health minister, Tedros is credited with overseeing the development of a community health care system across the country and sponsoring simple health care campaigns. But as a high-ranking official from a government that notoriously quashes dissent, who will Tedros consult when, say, an outlier group like Médecins san Frontières starts begging for funds to curb a disease outbreak?, experts ask. Will Tedros go to the nongovernmental organization or to the government minister concerned with threats to trade and tourism?
Tedros ambitiously said he wanted to increase member state dues to 51 percent of the total budget, but Dr. Chan has proposed a 3 percent increase after Germany’s proposal for a 10 percent raise was shot down by other countries. That would give the director-general a whopping $28 million more to use for unfunded mandates.
That’s “chump change,” said Steve Landry, director of multilateral partnerships at the Gates Foundation. “Member states should be embarrassed at the amount they provide. It’s totally incongruous. You’re giving an organization a task it can’t accomplish with minimal bequests.”
Gates Foundation teams work with the WHO as its regulatory and technical resources coincide well with the foundation’s interests in stemming polio and other communicable diseases. Landry’s team helps developing countries “prequalify” medications for distribution.
But though the WHO established “official relations” with the foundation in January, the foundation won’t have a vote in May. “It’s a very, very strange situation, which on balance has been a plus,” Garrett of the Council on Foreign Relations said. “But there’s no assurance that that will continue to be the case.”
It is hard to understand why these candidates want the job so badly. The $240,000 annual salary is not enormous. The financial picture is precarious. The constant travel wears out directors-general, Garrett observed, and distances them from their staff members. The WHO is positioned at a major crossroads, while health crises abound and donor countries retrench. Perhaps the three are risk-takers who have put representing the well-being of all people at the top of their bucket list.
“WHO is an important platform,” Csete of Columbia University said. “And at various times in history, it’s been an enormously respected and sought-after one.”
Deland, chief of staff for WHO’s Ebola response, said: “That is what WHO does. It provides world-class advice with the best network in the world.”
Dr. Chan weathered her share of such storms. Through a series of webposts that began on April 13, she has been wrapping up her tenure from 2007 to 2017, writing: “Together we have made tremendous progress. Health and life expectancy have improved nearly everywhere. Millions of lives have been saved. The number of people dying from malaria and HIV has been cut in half. WHO efforts to stop TB saved 49 million lives since the start of this century. In 2015, the number of child deaths dropped below 6 million for the first time, a 50% decrease in annual deaths since 1990. Every day 19000 fewer children die. We are able to count these numbers because of the culture of measurement and accountability instilled in WHO.
“In a world facing considerable uncertainty, international health development is a unifying — and uplifting — force for the good of humanity.”
The next director-general takes office on July 1, 2017.
This article was made possible through a grant from the Carnegie Corporation of New York and individual donors.