As the World Health Organization votes in a monumental open ballot for its new chief, the developing world and the developed world are in a battle of ideas.
- By Laurie GarrettLaurie Garrett is senior fellow for global health at the Council on Foreign Relations and a Pulitzer Prize winning science writer.
This week, health professionals from 194 nations will gather in Geneva to decide the fate of the World Health Organization (WHO). For the first time since its 1948 creation, every nation will vote for WHO’s new director-general, determining the future orientation and leadership of the controversial, underfunded agency. The U.S. delegation will be led by Health and Human Services Secretary Tom Price, fresh from last week’s journey to Liberia, where the Ebola virus raged in 2014.
There is a lot riding on this unprecedented election and other points of debate that will be thrashed in more than a week of meetings. For poor countries, the fight is about scarce resources, the paucity of trained health professionals, rising costs of medicines, and transfer of biomedical technologies from the West and developed nations. Middle-income countries want to build national health systems that meet the standards set by the likes of Singapore and Japan, bringing long life expectancies to nations as infectious threats diminish. And for the wealthier nations, including the United States, the future of WHO is strongly tied to health security: rapid control of epidemics, ensuring no lethal pandemic sweeps the planet as HIV did in the 1980s and influenza did in 1918, claiming the lives of tens of millions of people.
For decades, the leaders — and the priorities of WHO — have been decided behind closed doors by a small executive board, and candidates won their positions by making promises to about 30 ministers of health, representing the big donors like the United States and poorer nations that rotated periodically onto the board. Those promises, meant to be secret, have included vowing to back particular global health initiatives, guaranteeing top jobs to key country representatives or their relatives, spending millions of dollars to build clinics or programs inside a voting country, and even bribery. As I described in detail a year ago, I personally witnessed such bribery in the past and have seen a long list of outrageous demands on the part of executive board voters by former director-general candidates, including insisting on an appointment to Geneva (with subsidized private schooling) and demanding construction of a tertiary-care hospital in a country’s capital. Commonly, votes were swapped, as countries vowed to back one another’s candidates for a variety of U.N. positions.
For the first time, every nation will have a chance to vote in a one-country, one-vote process that gives equal weight to behemoths like China and India as well as miniscule Vanuatu and Lichtenstein. Voting will begin on May 23 by secret ballot and may go more than one round if none of the initial candidates garners a clear majority. Whoever proves victorious will take office on July 1, directing the troubled agency.
Three finalists are in the running, representing Britain, Ethiopia, and Pakistan. And as the election day nears, the differences between the candidates and their likely priorities for the future of global health are becoming more apparent. And lurking in the background is the Ebola virus, which re-emerged in late April in a remote region of the Democratic Republic of the Congo and is spreading, having so far caused 29 suspected cases, three deaths, and more than 400 additional contacts in a region rife with violent conflict and refugee movements.
Historically, the United States, Japan, Britain, China, France, and Germany have cast the key votes in this process. (The Bill & Melinda Gates Foundation — the second-largest donor to WHO — has cast a pivotal, but unofficial, ballot.) The leadership of world health efforts has reflected those nations’ top concerns. Margaret Chan, a Hong Kong-born physician, will step down this summer after 10 years in the job, leaving behind a mixed legacy. Propelled to the job by Beijing following China’s SARS epidemic humiliation, Chan’s candidacy was backed by an unparalleled Chinese surge in promises made to nations throughout the world, especially across the African continent.
The SARS virus, which eventually sickened more than 8,000 people, claimed 774 lives, and spread to 31 countries, first emerged in southern China in late 2002 but was covered up by Beijing authorities until April 2003. The official position of the Chinese Communist Party prior to that was that a tiny outbreak in Guangzhou was successfully stifled and that SARS was not a significant issue for mainland China. By the time Beijing admitted to having SARS, the virus was in every Chinese province, and the world community blamed China for the global outbreak. Beijing — determined to save face and never again be shamed for covering up an epidemic — identified Hong Kong’s Chan, who led her community’s aggressive response to the virus, as its choice for the next director-general of WHO. The 2006 campaign was hard fought by a field of excellent candidates, with China throwing a tremendous amount of money into hospitals and other health projects across Asia and Africa; Chan carried the day in a January 2007 executive board vote and was re-elected without opposition in 2012.
The United States ultimately supported Chan’s candidacy in both elections.
This week, the Donald Trump administration will send a delegation to Geneva, casting its first U.N. leadership votes and weighing in on a long roster of reforms and controversies slated for debate in the 70th World Health Assembly. Topping the list of debates will be WHO reforms meant to correct flaws in the agency’s slow and misguided initial responses to the 2014 Ebola epidemic in West Africa. The virus spread through Guinea, Liberia, and Sierra Leone, with isolated cases in other nations, for nine months before Chan declared a global health emergency, triggering the multibillion-dollar, multinational epidemic control effort that commenced in September 2014 and lasted well into 2016.
The U.S. delegation will be led by Secretary Price, accompanied by some HHS staff and the acting director of the Centers for Disease Control and Prevention (CDC), Anne Schuchat. Price and his staff have made no public statements regarding any of the candidates for WHO leadership or key issues on the World Health Assembly agenda. It is widely assumed, though not confirmed by HHS, that the secretary will cast his first vote for Britain’s David Nabarro, reflecting the Trump administration’s warm relationship with the post-Brexit government of Prime Minister Theresa May. It is also widely believed that the Barack Obama administration backed a different candidate, Ethiopia’s Tedros Adhanom Ghebreyesus — a point acknowledged to some degree in former CDC Director Thomas Frieden’s letter to the New York Times, praising the former Ethiopian minister of foreign affairs and health, who prefers to be called “Dr. Tedros.” He has received endorsements from many former Obama administration officials.
There is no indication that the United States, or any of the major donor states from Asia and Europe, backs the candidacy of Pakistan’s Sania Nishtar, a former minister of health and founder of the nongovernmental health-promotion group Heartfile.
In the end, the fight boils down to what seems to be a neck-and-neck race between Nabarro and Tedros, in which Nishtar could emerge at the very least a spoiler, even a surprise winner if the voting goes into multiple rounds with no clear majority victor.
Tedros received a unanimous endorsement a year ago from the African Union, committing all its 54 voting nations to the Ethiopian’s candidacy. Africa feels its time in leadership is long overdue, given that no health official from the continent has held the top post. In recent months, that full-scale commitment seemed to be weakening, as the British reached out to Anglophone nations with promises of aid money in an effort to build Nabarro’s voting base. U.S. Secretary of State Rex Tillerson may have unwittingly pushed the AU members back into a solid bloc, top diplomats told me, when he snubbed the scheduled April meeting in Washington with AU Commission Chair Moussa Faki, canceling at the last minute. Former Ambassador Reuben Brigety, who represented the Obama administration to the AU, called the Tillerson diplomatic fiasco “the dumbest thing in the world.”
Many Africans, as well as progressive humanitarian groups such as Médecins Sans Frontières (MSF), are convinced the Trump administration and U.S. Congress plan to radically reduce all forms of foreign assistance, including global health programs, in the fiscal year 2018 budget, as was laid out in the president’s “skinny budget” and a recently leaked draft of the foreign aid budget. With most aspects of WHO’s economic future seeming grim, and the agency operating now $300 million in the hole, any hint of a U.S. rollback in support raises anger in poor and middle-income countries. In a May 17 statement to the G-20 health ministers’ summit in Germany, MSF International President Joanne Liu chided, “G-20 governments need to be focusing on the well-being of people in the midst of emergencies and outbreaks rather than tackling this issue from the angle of the threat such emergencies or outbreaks pose to their own countries.”
Liu’s comments touch a sensitive nerve for much of the world, namely that the United States and other wealthy nations are only concerned about preventing the spread of diseases that might threaten their own populations and that foreign assistance programs are viewed in Washington, London, Tokyo, and Beijing as trivial. In a speech in Liberia, also on May 17, Price said, “We are here to show President Trump’s appreciation to Liberians for the work they are doing, and we will work side by side to develop the health workforce to solve remarkable challenges in the area of infectious diseases.”
In contrast, Tedros downplays the continent’s infectious diseases, placing emphasis on plans to build community-based health programs that can provide essential services to all. During Tedros’s years as minister of health, Ethiopia trained 40,000 community health workers, reduced its HIV rate, and lowered pregnancy-associated death rates in its female population. The Ethiopian and Eritrean diaspora communities have waged a Twitter war on Tedros, accusing him of responsibility for human rights abuses, improper distribution of food supplies amid famine in his country, belligerence toward neighbor states, and even sanctioning the torture of political prisoners. More recently, Georgetown University law professor Lawrence Gostin, who backs Nabarro’s candidacy, told the New York Times that Tedros deliberately covered up cholera outbreaks in his country, perhaps allowing thousands of people to die. Observers have argued that Gostin’s cholera disclosure was Tedros’s “Comey moment.” (The euphemism “acute watery diarrhea” is used in lieu of “cholera” in Ethiopia and Nile nations — I personally suffered the cholera-that-shall-not-be-named in Egypt as a result of exposure to Nile water in 1988.)
Meanwhile, Nabarro’s star is tightly linked to his decades of service inside the U.N. system, working in multiple agencies and directly for two former secretary-generals, Kofi Annan and Ban Ki-moon. If it can be said that a U.N. official is a company man, Nabarro is that, as most of his professional life has been within the system. For years he has functioned as the man secretary-generals call in to clean up massive messes and corral multiple agencies, such as during the 2005 H5N1 influenza pandemic, the botched Ebola response of 2014-2016, and most recently the Haitian cholera epidemic — for which U.N. Nepalese peacekeeping soldiers are blamed, having carried the bacteria in their bodies and contaminated water supplies following the 2010 earthquake.
Just as cholera seems to be upsetting Tedros’s apple cart, so it is the same bacterial disease that is Nabarro’s Achilles’s heel. This year, on Nabarro’s watch, Haiti has reported 5,095 suspected cases of the disease and 69 deaths; while that is roughly half the number seen by this time last year, and an 88 percent decline from the 2011 peak of 350,000 cases, the streams and rivers of Haiti are filled with the microbes, and infection is a new normal in the island nation — which hadn’t a single case of the disease before the U.N. unwittingly brought it into Haiti in 2010. Given its culpability, the U.N. promised to raise $400 million for Haiti’s cholera fight and mobilize antibiotics and vaccines as needed, but as of April just $17.7 million was raised and only $2 million deposited into accounts.
Among the many U.N. tasks assigned to Nabarro over the years is that of implementing the 17 Sustainable Development Goals and 169 targets every nation on Earth is meant to achieve by 2030. Goal No. 3 calls for “good health and well-being for all,” something that is achievable, Nabarro believes, through construction of effective health systems inside every nation. But as the U.S. Congress hashes out America’s own health system, most of Nabarro’s agenda conceives of WHO playing an advisory role, helping each country find its own health provision sweet spot.
Sania Nishtar faces the toughest fight — but not for any alleged sin she has made other than that of being born in Pakistan. China and India oppose her candidacy because she is Pakistani, and other opposition cite her lack of U.N. experience. The former Pakistani minister of health, were she to eke out the votes, would be the first person to serve as director-general since WHO’s 1948 founding who has devoted much of her working life to endeavors other than government and the U.N. Nishtar founded Heartfile to bring first-world cardiovascular prevention and treatment to developing nations, and both the NGO and its leader are embraced by the civil society community (which, of course, cannot vote, as only ministers of health may cast ballots). Nishtar’s vision for the future of WHO calls for absolute transparency regarding all of the agency’s funding and appointments, close collaboration with civil society and humanitarian groups, and significant reform of all WHO activities.
Nishtar is the only candidate who has vowed to serve a single five-year term, so as to guarantee she will not be swayed by vote-seeking and campaign fundraising. And she has promised that not a single vote will be won by giving away job appointments, bribes, or financial commitments of any kind.
While most observers give Nishtar little chance of defeating Nabarro or Tedros, there is a good possibility neither man will claim a 60 percent majority in the first round, freeing the process for some wild hallway horse-trading. I would hope that Nishtar’s transparency policies, commitment to NGOs and civil society, and her willingness to serve a single term might then prevail.
Perhaps some of the 194 voters might then recall that the greatest leader WHO ever had, Gro Harlem Brundtland, brought the institution back from another existential moment because she, too, insisted on serving a single term.
Photo Credit: John Moore/Getty Images