22 May 2017

Africa: WHO Vote – Will It Save Our Lives?

Photo: VOA News
Dr. Tedros Adhanom Ghebreyesus speaking at a press conference in Geneva launching his candidacy to head the World Health Organization (WHO).
analysis

Cape Town — There is high drama in Geneva as health experts worry whether politics will outweigh accountability and experience in tomorrow's down-to-the-wire balloting for Director-General of the UN World Health Organization.

A smear campaign three months ago derailed the expected selection of Nigerian physician Dr. Muhammad Ali Pate to head the Global Fund to Combat Aids, Tuberculosis and Malaria. This month a last-minute attack on the candidacy of Dr. Tedros Adhanom Ghebreyesus of Ethiopia has raised questions about whether wealthy western powers are prepared to accept African leadership of global health institutions.

But Tedros admirers in developed countries are fighting back. Ezekiel Emanuel, chair of the department of medical ethics and health policy at the University of Pennsylvania, defended him against what he called "terribly nasty" dirty tricks. Former head of the US Centers for Disease Control and Prevention, Dr. Tom Frieden, supported Tedros against charges that he had covered up an epidemic in Ethiopia.

Nicole Schiegg, a former senior advisor to USAID, the development agency, wrote that he is the leader the World Health organization needs. Before the last-minute attacks, British Conservative party politician Andrew Mitchell said Tedros was the best candidate to help developing countries make health gains – and also to protect the world against pandemics.

As former health minister of Ethiopia, with experience in numerous global health initiatives, Tedros won admiration for his strategic thinking, his management abilities and his skill at bringing together diverse constituencies towards achieving common health targets. His accomplishments in improving health and saving lives in Ethiopia have been cited as models for gains that can be made, even in difficult, low-resource settings.

The other finalists in tomorrow's election are Dr. Sania Nishtar of Pakistan, a cardiologist who has held several government portfolios, including health, and Dr. David Nabarro, a long-time United Nations official who served as UN Envoy for Ebola during the 2014 outbreak in West Africa that killed 11,325 people and caused international panic. [note: An article posted by an international legal rights organization - WHO's Reality Check - says that Nishtar's written resume is misleading: "Both the insinuation that she was Minister of Health as well as that she was responsible for health, however, appear to be untrue."]

Tomorrow's vote is about more than who will lead an international organization. Dr. Larry Brilliant, former head of Google.org, was involved in the campaign against smallpox – the only major infectious disease to be eradicated. His wish upon winning the 2006 TED Prize was "to stop pandemics".

Now chairing the Skoll Global Threats Fund, Brilliant led a panel on coming pandemics at the Skoll World Forum in Oxford last month. Participants agreed that deadly disease outbreaks are inevitable and that the World Health Organization's delayed and flawed response to the west African Ebola epidemic of 2014 was one of the signs that the institution needs major reform.

In an interview afterwards, panelist Suwit Wibulpolprasert, a senior advisor to Thailand's health ministry, said, "The World Health organization is broken. And the World Health Organization is our only hope." He said the process of electing a WHO Director-General – although much more transparent than in the past – is still about politics as much as about merit.

Tedros has unified support from the African Union, which has 54 votes in the balloting to lead the Geneva-based organization. Each of WHO's 193 national members has one vote.

Asked whether the fact that the smallest countries have an equal vote with the largest helps insure that merit will play a role, Suwit Wibulpolprasert agreed. But he noted that "small nations, such as tiny islands, are vulnerable to both pressure and financial incentives".

Conservative British politician Andrew Mitchell, who was UK Secretary for International Development, worked closely with Tedros on such issues as accelerating vaccinations against preventable childhood diseases and access to contraception.

Tedros reduced deaths of Ethiopian mothers in pregnancy and childbirth by "a staggering 75 percent".

"As Ethiopia's health minister between 2005 and 2012," Mitchell wrote, "he hugely expanded healthcare in one of the world's most difficult countries: he created 3,500 health centres … built more medical schools and deployed nearly 40,000 community-based health workers....

"Tedros's efforts to improve Ethiopia's health system were crucial to doubling the percentage of Ethiopian women with access to contraception. His efforts saw a reduction in maternal mortality of a staggering 75 percent."

Media-fueled attacks round one - the Global Fund

In the cases of both Dr. Pate and Dr. Tedros, articles in the New York Times by Donald G. McNeil, Jr. raised questions about their fitness to lead the international health bodies and prompted critical comments in other media.

Pate, as Minister of State for Health, led his country's complex, challenging and successful vaccination campaign against polio in conflict-wracked north-east Nigeria, where suspicion of health workers was widespread. After completing the campaign, he resigned from the ministry, where management issues were known to obstruct effective service delivery.

He has taught at Duke University's Global Health Institute and at Harvard, has advised the Gates Foundation, and recently was tapped to run the new Big Win Philanthropy by founder Jamie Cooper. He co-chaired a panel on lessons learned from Ebola in west Africa with Dr. Peter Piot, the Belgian physician who identified the virus in the first known Ebola outbreak in 1976.

Few global health experts were surprised that Ali Pate was the top choice of the Global Fund's Executive Director Nominations Committee in February, after a three-month search and rounds of interviews with prospective candidates. The search committee's report said "Pate brings a compelling and relevant mixture of experience as a public health research and policy specialist and a leader of health program delivery and system reform". But on 15 February, two days after the report was presented to the Fund, McNeil reported that the appointment of Pate might threaten U.S. support, which accounts for a third of the Fund's annual budget of around US$4 billion.

The New York Times article, inaccurately calling Pate the former Nigerian Minister of Health – in fact, as minister of state he served below the minister – said he "has used Twitter posts to call Mr. Trump a fascist…"

Pate himself points out that nearly a year before Trump's election he had shared a link to a Time article by U.S. basketball hall of famer Kareem Abdul-Jabbar, a U.S. ambassador for culture, "trying to promote American values of tolerance for diversity and love for humanity" after candidate Trump proposed a Muslim ban. In July, four months before the election, Pate shared with his Twitter followers a New Yorker article by Adam Gopnik. In neither case did he comment on or endorse what the authors said.

After the McNeil article was published, not-for-profit health organizations in Nigeria revealed that they had been asked by people interested in the Global Fund selection if they could supply instances where Dr. Pate, a Muslim, had favored Muslims over Christians in his work at the ministry of health.

AllAfrica has not independently verified that those questions were posed, though the reports come from several sources. Pate, who is now an American citizen, says that he has utmost respect for the office of president of the United States and would never do anything to demean it.

In the wake of the New York Times story and numerous reports citing it, the Global Fund, giving a confusing series of reasons, halted its scheduled announcement of a new director and said it would restart the search process, leaving the organization without an appointed director when the current director leaves at the end of this month.

"It was a real disgrace what happened," said Dr. Piot in an interview this month in London, where he heads the London School of Hygiene and Tropical Medicine, one of the world's top global health research and teaching institutions. "There were very capable candidates, and the lead candidate, Dr. Muhammad Pate, has everything to be an excellent leader of the Global Fund. Then through political maneuvers which are not clear – I was not involved in that – there was no election. For one of the most successful funding mechanisms in global health to be hijacked by this kind of national and political agendas is a real disgrace, and I hope will not result in people dying."

Media-fueled attacks round two – the World Health Organization

Nine days ago on 13 May, Donald McNeil published a New York Times article with the headline Candidate to Lead the W.H.O. Accused of Covering Up Epidemics.

The article quotes Lawrence O. Gostin of Georgetown University in Washington DC alleging that Tedros had covered up three cholera epidemics when he was minister of health – "a charge that could seriously undermine his campaign" to run WHO, McNeil wrote. As happened after the Global Fund article about Pate, other media amplified and quoted the New York Times piece.

Ezekiel Emanuel and Tom Frieden were quick to respond. Emanuel called Gostin's allegations against Tedros "an unsubstantiated charge". He said labeling such outbreaks in rural areas as "acute watery diarrhea" is common, because they are hard to diagnose.

Emanuel said he had co-authored papers with Gostin, who was normally a careful scholar, but questioned "why a decade-old charge was launched only in the waning days of the WHO campaign" – and noted that Gostin is a Nabarro advisor.

Interventions by Tedros have saved millions of children's lives from preventable diseases, malaria and malnutrition.

"All global health experts agree," Emanuel wrote, "that because of the community health care workers and other programs initiated by Tedros, Ethiopia has made dramatic improvements in infant and maternal mortality, malaria mortality, immunization rates, and childhood nutrition.  For instance, since 2005 infant mortality in Ethiopia has dropped by 23 percent and the number of malaria cases per year declined nearly in half from 3 million to 1.7 million. Indeed, unlike most sub-Saharan African countries, Ethiopia achieved all but one of the Millennium Development Goals in health."

Tom Frieden quickly responded to McNeil's article. In a letter to the New York Times, the former CDC head said that, while not optimal, many countries report cases of "acute watery diarrhea" to the WHO, as Ethiopia did, enabling case reporting and response without laboratory confirmation. Frieden wrote that Tedros created a network of nearly 40,000 women community health workers who were "trained, supported and supervised" to prevent deaths from diarrhea and other causes. "The world would be safer and healthier", Frieden said, if the WHO facilitated such programs in more countries.

Questions about Nabarro

A number of Africans in Geneva for this week's World Health Assembly are wondering why what they regard as thin critiques of Pate and Tedros have not been matched by media discussions of other candidates.

In particular, several cite the slow, inadequate response of the United Nations and the World Health Organization to Ebola in Liberia, Guinea and Sierra Leone, with its high death toll, at a time when Nabarro was a senior UN official for the Millennium Development Goals and, beginning in August 2014, the UN's Ebola envoy.

While they credit Nabarro with accelerating the pace of response as envoy, they say much more could have been done sooner. And they fault UN officials for not doing more to combat the unscientific travel bans and the quarantines of shipments of life-saving medical supplies to the region.

One news organization that has raised questions about Nabarro's policies if he gets the WHO job is the Sydney Morning Herald. Latika Bourke reported on 15 April that Nabarro's stance against a 'sugar tax' ahead of a visit to court the support of Australia was regarded as "passing strange" by the movement to curtail dietary sugar. Sugar is Australia's second largest agricultural export.

Bourke points out that Nabarro's stance is at odds with the British government that is backing him. A sugar levy is due to take effect in the UK next year in an attempt to curb obesity and diseases like diabetes.

She refers to a study that says Australia's government could save billions of dollars as well as lives by fiscal policies that reduce consumption of sugar, salt and certain fats, and she cites research that says a tax on sugary drinks alone could increase revenues by $520 million annually. But Australia's Conservative government supports industry in opposing the levy – and it's the government that casts Australia's vote in Geneva.

Whether or not David Nabarro is tailoring his positions to collect support, those who know Tedros says he has been a steady, persuasive presence in global health councils for years, nudging the Global Fund Board, on which he served, to better fiscal accounting and more efficiencies, working with GAVI to expand immunization coverage, promoting universal access to health care and to contraception services for women.

In a lunch with AllAfrica editors early in his campaign, he outlined the vision that continues to animate his approach: bold transformation of WHO to meet pressing global threats and needs, including pandemics, antibiotic-resistant infections and the health effects of climate change, alongside the problems that still plague much of humanity.

It is his consistency, his achievements and his collegial nature – urging and demonstrating rather than lecturing – that persuaded Dr. Senait Fisseha, professor of obstetrics and gynecology at the University of Michigan, mother of four and founder of the Center for International Reproductive Health Training, to campaign for Tedros. She has traveled constantly over the past year because she is determined that he will lead the WHO.

"It's not because it's 'Africa's turn'", she told AllAfrica. "It's because we all need him there. Whether you live or die shouldn't depend on what part of the world you're from." She's fortunate, she says, that her university believes that part of its moral imperative as a large, public educational institution is to address health inequities.

In a few hours, we'll all know whether that vision prevails in Geneva at the World Health Assembly.

The other finalists in tomorrow's election are Dr. Sania Nishtar of Pakistan, a cardiologist who has held several government portfolios, including health, and Dr. David Nabarro, a long-time United Nations official who served as UN Envoy for Ebola during the 2014 outbreak in West Africa that killed 11,325 people and caused international panic. [note: An article posted by an international legal rights organization - WHO's Reality Check - says that Nishtar's written resume is misleading: " Both the insinuation that she was Minister of Health as well as that she was responsible for health, however, appear to be untrue."]

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