The World Health Organisation (WHO) has a new Director General (DG). Ethiopia’s Tedros Adhanom Ghebreyesus will take over the reins of the world health body in a month from now at a time of great expectations and greater tumult. His job will not be easy. On the one hand, he is expected to be the world’s leading public health diplomat who can bang heads together and seek funds and resources for WHO. On the other hand he will be caught in the quagmire of WHO's Secretariat work, the regional meetings and endless processes which will directly challenge the first. Countries including the US have already warned they will pull funds if performance dips further
Since his election, Tedros (as he is called) has received a lot of advice, mostly from usual suspects in western capitals and western public health journals. Most of this advice is useless, framed as they are in Bretton Woods thinking looking for renewal. I find it odious that for years people who have contributed to almost killing the WHO narrative now advice the new DG on what needs to be done. The WHO – strapped for cash and looking for relevance – did not get here all by itself. We, you, us - governments, academics, doctors, advocates, journalists – have all played a role in turning the world’s only public health policy-setter – into a bureaucracy packed with limited talent and low low politicking. I choose that word carefully. Public health work is political work. Politicking is for the failed and the fearful. The new DG will have to undertake root and branch changes, be audacious and ambitious and pick the best people in the world to get WHO back on track.
That will not be easy. His campaign was framed as that of the first African DG and there is serious merit in that argument. After he was elected, he is being called the voice of the developing world. That too is worth its weight. After all, the WHO’s achievements under all DGs from the developed world have not been too spectacular, to say the least.
The best piece of solid advice I have read came from Richard Horton, Editor, Lancet. He said “…your predecessors have often been risk averse in leading the international community. The mantra of serving member states has made the agency fearful, defensive, overcautious, reactive, weak, craven, timid, unimaginative, pusillanimous and even paranoid. Be courageous. The voice of the voiceless. Politics – and health – is about people. WHO represents those who have no voice. When you are told why something isn’t possible…remember those who depend on you to improve their lives.” Read here.
Geographical representation – one of the campaign promises of the new DG – can cut both ways. All things being equal, that is the way to go, but countries are very rigid about their IOUs. Talent is not primed, there is in-fighting among WHOs top dogs and there is zero mentoring of young people who are seen as threats. The organisation has many quick-change artists (the DG is dead, long live the DG) for whom public health is a power point presentation. Racism – real and reverse – is rampant in the WHO including how the organisation deals with journalists. Most recently during the election process when all media was kept strictly kept out, an American journalist Laurie Garret, a former critic of Tedros, was allowed a sneak peek and she tweeted about it. This sense of entitlement has to stop and the WHO has to realise that social media is powerful tool. They will be called out systematically and if they trip. The answer to this is more openness, not become so inward looking that so inward looking that the simplest of questions, say by intelligent and new media, is seen as a threat.
The media is the WHO's friend. Let that penny drop loud and clear. Public health and journalism are public good to be accounted for publicly and it is important for Tedros and his team to engage with intelligent opposition, not friendly fire. The organisation’s real power is a moral one – setting global standards and advocating them right down to the last person on earth. It is the only organisation that can declare a global public health emergency. For it’s word to be taken seriously and without fear, streams of trust must be built, stories must be told and shared. The WHO has said it is only a matter of time for the next outbreak to hit the world. The Ebola crisis which left some 11,000 people dead was an example of where, how and why the WHO failed itself and us. Allegations around Tedros in the run up to the campaign included covering up on Cholera and human rights issues in his country. It was written about by many journalists and I tweeted about protests in Geneva - the first time such events have taken place for a top for UN job. At the end of last week, the world discovered that India had failed to report Zika cases. There is much work to be done in the area of trust-building, demystifying jargon behind which WHO officials hide their inefficiency, laziness and fear. This election has drawn unparalleled attention and the world will hence forth watch closely as it should have all these years.
Trust is neither a hashtag nor a badge. It is a shared and felt responsibility. It has to be gained everyday through empathy, not sympathy and interminable documents that cost money to produce and no one reads. It cannot be built through more meetings and frequent flyer miles. For too long the WHO has hidden-behind fig leaves called technical meetings which result in more confusion and more meetings. Their job is carried forward in developing countries including in India where think tanks do largey irrelevant work promoting promoting nepotism and it's first cousin which is low quality work. I know I am being harsh, but the reality of death and disease is much worse.
I can write chapter and verse about how we cannot expect WHO with a $2 billion annual budget to perform miracles. That’s an old narrative and nobody expects it to. Let us get this straight. There will will never be enough money for the WHO to do what is wants and in that search it has to be in close contact with what people want - people not based in Geneva and New York - but where the disease burden is most felt and least attended to. A piece in the BMJ primes Tedros time as his country's Foreign Minister as an inroad to the high tables. There reality is Foreign Ministers rarely have the time of day for their counterparts from the health ministry an when national budgets are cut, health gets the rest after the heavy ministries - typically home, defence, foreign, infrastructure - have had their say. Interestingly, all the expert advise to Tedros Adhanom also spoke about western donors. Nobody spoke about China and it’s emerging presence in the United Nations (UN) system and this comes with resources as well. Besides large public donors in the US, though vary will certainly buffet the process to a point. Many large western donors had backed Dr. David Nabarro who, on merit alone, was best placed to get the job.
One thing is certain - this is 2017, not 2000. Money will go where it is seen as safe and productive. Travel costs in the organisation are scandalous. The Global Health Fund next door has seen renewed money and resources and there's a new and health facility coming up in the city. One of Tedro's priorities is women’s health. That brings him into direct conflict with the United Nation’s population fund (UNFPA) as does work on children and adolescents which is largely under the UNICEF. In fact Geneva has innumerable health centres in some kind of a relationship with WHO adding nothing new to the voice of people around the world but taking away valuable credibility.
Time is now for Tedros to show his leadership skills. He will have to break the old moulds as swiftly as possible. A biologist by training he was Health and Foreign Minister of Ethiopia and has also served as member of boards of prestigious global public health bodies. The expectations are high. As his transition team works through, I found one of the initiatives very positive. They reached out to nurses, the silent warriors of public health who are always on the frontline of death and disease and without whom public health work will come to a standstill. From the anganwadi workers to those who work in the world's top clinics, from women and men who handle Zika and Ebola to those who attend to patients with HIV/AIDS, TB, mental health - in other words, the daily drudge of this work in difficult conditions, must be better profiled and paid. They are critical allies we must all reach out to and treat with dignity and respect. If memory serves me right, the WHO has two nurses on its staff. That says a lot about the organisation. Hopefully, Tedros will be able to inject reality into messy machine he has inherited.
Full disclosure: Subramaniam and Dr. David Nabarro (who lost to Tedros ) were former WHO colleagues.
Note: Subramaniam does not use the prefix Dr. for Tedros as he is not a medical doctor. International view and deontology is deeply divided on this matter and she stands with the school that says only medical doctors can do so, especially in public health where it has great significance.