The Campaign to Lead the World Health Organization

http://www.nytimes.com/2017/04/03/health/the-campaign-to-lead-the-world-health-organization.html

Version 0 of 1.

In May, the World Health Organization will select a new director general, a choice that will affect the health of hundreds of millions in the developing world — perhaps even more if a global pandemic were to emerge.

For the first time, the selection will be made by a vote of the W.H.O.’s member nations for candidates who have campaigned openly for the post. The changes are intended to introduce some transparency into the process. Until now the job, held by Dr. Margaret Chan since 2006, has been filled after quiet horse-trading among major nations, sometimes involving accusations of bribery.

The three candidates are Tedros Adhanom Ghebreyesus, 52, a malaria expert and former Ethiopian health minister; Dr. David Nabarro, 67, a Briton who has led the United Nations response to various disease outbreaks; and Dr. Sania Nishtar, 54, a cardiologist and, briefly, a Pakistani government minister who is an expert in obesity and heart disease.

The election comes at pivotal moment for the W.H.O. The organization that the candidates hope to lead has reached a crossroads, and many experts believe it suffers from a crippling identity crisis.

Critics often dismiss it as another lumbering United Nations agency paying tax-free salaries to technocrats to live in Switzerland and churn out reports. At times, the agency lives up to the stereotype: Media officers have been known to plead that they cannot find an expert to take a brief phone call “because it’s dinnertime here in Geneva.”

But as soon as an epidemic like Ebola or Zika strikes, the world expects the W.H.O. somehow to launch a corps of medical paratroopers, storming ashore in West Africa or Brazil to save the citizenry from another plague.

In fact, there is no battalion of jungle-hardened doctors polishing syringes in Geneva. The budget for that small division was cut after the 2008 fiscal crisis.

Instead, the agency has come to rely on medical charities like Doctors Without Borders to respond first to crises, while officials appeal to donor nations to contribute money and doctors.

The W.H.O. is hampered by severe bureaucratic limitations. It has 194 member states — represented by their health ministers, who can be fractious. It has 150 local offices and six regional ones, staffed by officials with local political connections. Infighting between headquarters and the Africa regional office was blamed in part for the failure to respond quickly to the 2014 Ebola epidemic.

Its annual budget is only $2.2 billion — half that of NewYork-Presbyterian Hospital. Only 30 percent comes from United Nations dues; the rest is donated.

The biggest donors, like the United States, Britain, the Bill & Melinda Gates Foundation, Rotary International and Norway, often give money with strings attached. Eradicating polio, for example, consumes much of the agency’s time, even as donors press officials to open new fronts against obesity and mental illness.

The director general is also under pressure from competing lobbies. Pharmaceutical companies, for example, donate drugs but push to protect lucrative patents, even as poor countries demand access to patented drugs.

Food companies want credit for making infant formula and nutritious food, without having agency officials accuse them of undermining breast-feeding or spreading diabetes with colas and snacks.

Tasks that once belonged to the W.H.O. have been wrested away. For example, although it oversees emergency vaccine stockpiles for yellow fever and cholera, other agencies now oversee childhood vaccines.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is now the main conduit for fighting those diseases — and has $5 billion a year to work with.

The World Bank raises money for pandemic responses. And the Gates Foundation, through the Seattle-based Institute for Health Metrics and Evaluation, has claimed for itself a core W.H.O. role: “diagnosing the world’s health problems and identifying the solutions.”

Nonetheless, the W.H.O. remains essential, especially in crises. Only this agency can declare a global health emergency. And while countries often resist revealing disease outbreaks for fear they will hurt tourism, food exports or national pride, they are obliged as United Nations members to report to the W.H.O.

The W.H.O. oversees cooperation among national laboratories, turning them into a vast surveillance network for fast-moving diseases like avian flu. The agency also sets global medical standards, such as deciding which generic drugs are safe, what essential drugs every hospital should have, and how best to treat diseases. Poor countries badly need that help.

The next leader will have a full plate.

The election will work on the principle of one country one vote — Liechtenstein will have as much say as China. It will be by secret ballot, so if deals are cut during a runoff, it will be hard to tell who switched sides.

Virtually all global health experts interviewed about the candidates spoke on condition of anonymity, for fear of alienating the future winner. Privately, several predicted a runoff between Dr. Nabarro and Dr. Tedros; the outcome will depend on which way nations in the Americas, East Asia and parts of Europe swing.

Dr. Nabarro is well-known to the big donor nations. Dr. Tedros has the endorsement of the 55-member African Union, but is hurt by Ethiopia’s dismal human rights record. Dr. Nishtar’s support is uncertain.

There have already been reports of behind-the-scenes politicking. The African Union strongly feels that it is an African’s turn to run the W.H.O.

But when two names from French-speaking West Africa were floated — Dr. Awa Marie Coll-Seck, former health minister of Senegal, and Michel Sidibé, the Malian head of Unaids — French officials reminded their governments that France expected support for another candidate, Dr. Philippe Douste-Blazy. Yet he was voted out in the first round in January.

Previous elections have been tarnished with rumors of bribery. Laurie Garrett, of the Council on Foreign Relations, recently recounted an incident she witnessed at W.H.O. headquarters in 1991. A furious East African health minister, she said, flung a rug into a marbled hallway, shouting at terrified diplomats: “A rug? You think you can buy my vote with a rug?”

The minister complained that other voters had been offered new hospitals, jobs for relatives and school tuition for their children.

On most issues, the candidates’ positions are similar. All favor more transparency and efficiency. All want a bigger W.H.O. budget that they control, and all fear the Trump administration will cut donations.

All want to restore the agency’s pandemic response capabilities. All believe drugs and vaccines should be cheaper. All want more focus on global warming and human health.

But in interviews with The New York Times and in public forums, the candidates have dodged some fundamental questions. None will say what they will cut from the agency’s strained budget. None will name any countries, foundations or corporations they think have too much influence.

All three candidates are crisscrossing the world, trying to persuade governmental health ministers to swing to them. But “being competent is not enough,” said Lawrence O. Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University.

“This is a deeply political election,” he said, “where merit often comes second to regional politics.”

Following are short profiles of the three candidates to lead the W.H.O.

Dr. Tedros, 52, who uses his first name in his campaign, is relaxed and not as instinctually wary as many diplomats. He once let a reporter interview him in his hotel room as he changed clothes for an event.

Dr. Tedros takes his work to heart. In an interview he described fighting a malaria outbreak as health minister in Ethiopia as “a good opportunity for me to retaliate, because my inside was boiling.”

He wanted revenge on the disease itself, he explained. His first assignment as a medical officer, 20 years earlier, came amid another outbreak of malaria that killed whole villages, and infected him as well.

His top priority as leader of the W.H.O., Dr. Tedros said, would be health insurance for all, based on models in Ethiopia, Rwanda and Sri Lanka.

He has strong defenders, including some former aid officials in the United States. With American help, he reformed Ethiopia’s health system during seven years as its health minister.

He trained 40,000 female health workers, hired outbreak investigators, improved the national laboratory, organized an ambulance system and multiplied medical school graduates tenfold. Deaths from AIDS, tuberculosis and malaria, as well as deaths of young children and women in childbirth, fell by more than 50 percent in the country.

But Dr. Tedros has very vocal enemies in the Ethiopian diaspora. From 2012 until recently, he was the country’s foreign minister, and during this time the government suppressed dissent.

Human Rights Watch and Amnesty International reports describe villages displaced, protesters massacred by the police, dissidents tortured and journalists imprisoned.

Dr. Tedros is not accused of participation, but he is among the ruling party elite. The rights violations “should never have happened,” he said.

He is backed by the African Union.

Perennially on the road, Dr. David Nabarro is a war horse who has seen many medical battlefields — but still champs the bit for more.

A British citizen, he first went into the field with Save the Children in Iraq in 1974. Since joining the World Health Organization in 1999 to run its malaria control program, Dr. Nabarro has led the responses of various United Nations agencies to avian flu, Ebola, cholera in Haiti, hunger and climate change.

He lost some of his hearing in the bombing of the United Nations headquarters in Baghdad in 2003. His Boris Karloff-like voice is perfect for an expert in epidemics: If he read “Peter Rabbit,” it would sound like “The Doomsday Chronicles.”

He knows everyone in global health and has fought some sharp-elbowed power struggles; he once lost a bid to run the influential Global Fund to Fight AIDS, Tuberculosis and Malaria. Sophisticated about media, he carefully goes off the record before unsheathing any daggers.

Even after losing the race for a coveted position, Dr. Nabarro often gets appointed as a special envoy because he is skilled at organizing medical campaigns.

As leader of the W.H.O., he would like to shake up “the 9-to-5 culture in Geneva,” he said. “The W.H.O. will not be a sluggish and rusty bureaucracy under me.”

He is seen as the most forceful candidate; how much that helps remains to be seen, since health ministers often admire forceful leadership only when it is applied to others.

He is strongly backed by the British government and is well-known to all the major Western donors, but none have made public endorsements.

Dr. Sania Nishtar comes from a prominent political family in Pakistan and acknowledges that she lives “a comfortable life in Islamabad.” She graduated at the top of her medical class and strikes some experts as a star pupil, qualified more because of her intellect than for her experience.

Her career has been largely that of an advocate and critic, serving on World Health Organization committees and speaking, for example, at the World Economic Forum in Davos. She founded Heartfile, a think tank devoted to health care reform, and was a health minister for two months in a caretaker government.

Her campaign résumé runs 38 pages, but when pressed to put her strongest qualification in a sentence, she struggled, finally submitting answers in writing later. They described her as a champion for transparency, accountability and prevention of noncommunicable diseases.

She tends to the development-speak endemic to United Nations agencies — she does not shy from expressions like “transformational leadership through capacity-building in resource-challenged environments.”

Her vision of the W.H.O., she said, is of “a knowledge lighthouse” that collates the world’s best medical practices. She wants to shrink its budget with less printing of reports and less expensive travel.

Asked how she would have handled recent epidemics, Dr. Nishtar said she “would have issued the wake-up call on Ebola” much earlier. On Zika, she would have had “no hesitation about telling women that they could delay pregnancy” and urging officials to offer contraception.

In public forums, she has looked a bit left out as Dr. Nabarro and Dr. Tedros, who know each other and have sometimes clashed, jokingly tussled over a microphone and dropped the names of former W.H.O. leaders they had worked with.

Her regional support remains unclear.