Wanted: A fighter for global health to lead the WHO
24 Sep 2016 - 14:50
The view outside the office of the head of the World Health Organisation dazzles, stretching across Lake Geneva to Alpine peaks. The view inside is less inspiring: dated furniture and listless pot plants dot the seventh-floor office of Margaret Chan, the WHO’s Director-General.
Understated decor suits her style. “I am an international civil servant,” she told Reuters in an interview. “I am here to facilitate countries to discuss and find solutions.” Chan’s low-key, consensual approach has held sway at the organisation for nearly a decade. A Chinese former teacher and doctor, she says it has brought lasting results - such as progress towards universal health coverage and improved pandemic preparedness.
“If you want to be successful in global public health ... you need to bring all partners together,” she said. Quoting what she said is an African proverb, she added: “If you want to go fast, you go alone. If you want to go far, you go together.”
But as her second five-year spell at the top heads towards a close, numerous public health experts say consensus is no longer enough. In May, 10 influential global health specialists wrote to the British Medical Journal (BMJ), saying of the WHO: “Business as usual cannot continue; transformative leadership is called for.” The UN agency requires strategic reform, they said, and needs a bold new director general who can command the world stage.
Reuters has spoken to eight more specialists who voiced similar views. Jeremy Farrar, director of global health charity the Wellcome Trust, says whoever takes over from Chan has to “inspire a sense that the organisation knows what it’s doing, inspire confidence in the member states, and inspire the best people to want to work there.” In their view, the WHO is losing influence, and at risk of losing more. Despite being a global body, the WHO’s spending power is relatively modest: $4.3bn over two years compared to almost three times that at the US Centres for Disease Prevention and Control.
Other organisations are attracting big funding from global health philanthropists and making strides in key fields outside the WHO. They include GAVI, the alliance created to improve access to vaccines for children in poor countries, and the Global Fund for AIDS, Tuberculosis and Malaria. More recently, the task of tackling antimicrobial resistance - the global spread of superbugs that are not susceptible to antibiotics - is being led not by the WHO but by an independent team headed by Jim O’Neill, a well-connected former Goldman Sachs economist.
Much will depend on the WHO’s next leader. Richard Horton, editor of the influential medical journal The Lancet, said: “The WHO needs a director general who can speak truth to power.” He said he is “very optimistic” about what could be done at the WHO by the right sort of personality at the top. “If you have the right person, it’s a fantastic opportunity,” he said. “If you have the wrong person, then it’s paralysis and failure.”
Chan said it was necessary to “listen and reflect” on what the WHO’s critics say, but that “it doesn’t mean I agree with all the criticism.” She added: “In any job there are barriers to what you can do. Having worked in the WHO now for 13 or 14 years, I understand what you can do and what you can’t.”
Changing the WHO, which has 7,000 staff spread across 150 offices worldwide, won’t be easy. Some member states, such as those in parts of sub-Saharan Africa, have vastly different health systems to those in richer Western countries. The result:
Local political interests can get in the way of global health priorities. Against that background, the WHO has gained a reputation for electing directors general who are risk-averse. Talk WHO history with senior figures in global health, however, and the name of one leader stands out: Gro Harlem Brundtland. A former prime minister of Norway, Brundtland was elected WHO director-general in 1998.
Chris Murray, a professor of global health at the University of Washington and director of the Institute for Health Metrics and Evaluation, said of Brundtland: “She was the sort of visionary, highly-principled leader who always did what she thought was needed for the world, whether or not that was politically convenient.”
David Heymann, who was previously executive director of communicable diseases at the WHO, describes how he awoke to a phone call on March 15, 2003, from the WHO’s infectious disease duty officer. It was to alert him to an outbreak of what later became known as SARS or Severe Acute Respiratory Syndrome.
Within hours, Heymann’s team had gathered evidence of cases in Canada, Hong Kong, Vietnam and Singapore. They assessed it and informed Brundtland. This prompted Bruntland, who declined to be interviewed for this article, to issue a global outbreak alert the same day and a call for authorities worldwide to work together to halt the disease’s spread.
In contrast, in 2014 the WHO watched for eight months as Ebola infections and deaths in West Africa rose before declaring the outbreak a global health emergency. The deadly viral disease raged for over a-year-and-a-half, claiming lives in six countries, and was only narrowly stopped from taking hold in Lagos, Africa’s largest city.
Chan said there was no doubt that during the Ebola crisis “we all could have done better,” though she gave no specifics. She pointed out that the two outbreaks occurred in different contexts: SARS in developed countries with good health systems, and Ebola in poverty-stricken countries with poor health surveillance.
Nevertheless, some experts were critical of the WHO’s handling of the epidemic. They noted that the international medical charity Doctors Without Borders warned early on that the epidemic was “unprecedented” and “exceptional”, but that the WHO failed to recognise the seriousness of the outbreak, describing it as “relatively small still.”
When the Harvard Global Health Institute and London School of Hygiene & Tropical Medicine reviewed the response to Ebola, their report found the disease had “exposed WHO as unable to meet its responsibility for responding to such situations.” Its report set out 10 recommendations for reform, including developing a strategy to monitor national capabilities, strengthening incentives to report outbreaks of disease and ensuring the next director general has “proven high-level political leadership.”
To be sure, the WHO has already made some changes since Ebola. Chan has established a new programme to manage health emergencies, with surveillance and preparedness at its core. When the Zika virus emerged as a threat in early 2016, the WHO responded more swiftly, and won plaudits for doing so. But some experts believe more could and should be done to improve the WHO’s performance.
Peter Sands, a former chief executive officer of Standard Chartered Bank and now a senior fellow at Harvard with an interest in health, argues that more attention should be paid to the economic impacts of global health. The WHO and its leader would gain clout if they better highlighted the economic costs of poor health systems and infectious diseases, he said.
Sands is chairman of the Commission on a Global Health Risk Framework for the Future, which estimates that pandemics have the potential to inflict economic losses of more than $60 billion a year. He suggests one way to get government ministers to take more notice of the WHO would be to publish objective assessments of each country’s “public health core capabilities” - things such as disease surveillance, laboratory testing, and research capacity.
Just as countries are influenced by reports on their economies by the International Monetary Fund and World Bank, WHO rankings could spur countries to improve their health systems, Sands said.
Chan disagrees, saying her job is to help countries, not judge or rank them. She likened her style to a parent seeking the best from her children: “When you encourage and motivate then, they do better. But when you keep hammering them, they get down and withdrawn.”
In a bid to be more transparent about how it chooses its director general, the WHO has introduced a new selection system. Previously, the 34 members of the WHO’s Executive Board considered various candidates and chose one. That candidate was then rubber-stamped by the 194 member states that make up the World Health Assembly (WHA).
The system lent itself to horse-trading between blocks of countries who would band together behind a series of promised deals to push their preferred candidate to the front. This time, the Executive Board will select three candidates to go forward to the full WHA, which will vote on the final choice. The three shortlisted candidates will work alongside Chan from January 2017, with the final selection made by the WHA in May 2017.
When nominations closed this week, six candidates had been put forward to succeed Chan. They were Ethiopia’s foreign minister Tedros Adhanom Ghebreyesus; Flavia Bustreo of Italy, an assistant director general at the WHO; Philippe Douste-Blazy, a French former minister of health; Sania Nishtar, a former minister of education and training in Pakistan; Miklos Szocska, a former health minister for Hungary; and David Nabarro, a British public health and nutrition expert with long experience of working at the WHO and the United Nations. He was appointed the UN secretary general’s special envoy on Ebola in the midst of the Ebola crisis.