From 1 July the world’s senior health official will, for the first time ever, be an African. What will this mean for global health? In the end, the race wasn’t even close. In the style of a champion long distance runner, Tedros Adhanom Ghebreyesus of Ethiopia (Dr Tedros) took the lead early in the competition.
He was the first to declare his intention to run, first to receive a major endorsement (from the African Union) and was top of a poll held in January to decide the final shortlist. Dr David Nabarro of the UK mounted a valiant challenge over the final few laps, but the Ethiopian was too far out in front for him to catch. Dr Tedros crossed the finishing line as victor on 23 May at the World Health Assembly in Geneva after three rounds of voting.
What we learned about the process
The election process has been fascinating for WHO watchers. This has been the first Director-General election where all 194 WHO member countries could vote. It was also the first held in the social media age: the last contested election, won by Dr Margaret Chan of China (Hong Kong), took place in 2007. All the things that went on out of public view in previous elections could now be followed on Twitter. We could track the candidates @DrTedros, @davidnabarro and @SaniaNishtar (the candidate from Pakistan and the only woman on the shortlist) as they toured the world seeking support. We could even follow the (supposedly secret) voting process on 23 May more or less live. Because of this I can report, based on well placed sources (i.e. the consensus on Twitter), that the result of the first round of voting was:
- Dr Tedros 95 votes
- Dr Nabarro 52 votes; and`
- Dr Nishtar 38 votes
Dr Nishtar, as the candidates receiving fewest votes, was eliminated. A second round of voting was held, but with the remaining candidate needing two-thirds of eligible votes. This put the threshold at 122 (although WHO has 194 members, 10 countries lost their right to vote because of unpaid membership contributions!). Dr Tedros’s supporters were already pointing out on Twitter that even if all Dr Nishtar’s votes went to Dr Nabarro, the Ethiopian was still invincible. In the even most of Dr Nishtar’s votes went to Dr Tedros. The result of the second vote was:
- Dr Tedros 121
- Dr Nabarro 62
In the third round Dr Tedros only needed an absolute majority of eligible votes (98). His supporters were celebrating on Twitter even as the voting took place.
Africa is the biggest user of WHO’s services, but WHO has never been led by an African. The sentiment that “it is time for an African Director-General” prevailed. This can be seen as a triumph for African diplomacy, with the African Union showing it can act as an effective power-block, and of course for Dr Tedros. The African Union endorsed Dr Tedros as its candidate as far back as January 2016, some 9 months before the election process even started. He was always going to be the man to beat. Among the “global health commentariat” (informed journalists, bloggers and experts) there was the view that Dr Nabarro might be able to overtake him in the final lap. Dr Tedros had the political baggage of Ethiopia’s less than perfect record on human rights and democracy. Dr Nabarro was strongly supported by the UK, one of the world’s largest aid donors, which could maybe make promises of extra spending on health projects….. In the end the world’s health ministers voting in the World Health Assembly proved less interested in Ethiopia’s human rights record than the “global health commentariat” (who don’t get a vote). And maybe the UK is less popular and less credible in the age of Trump and Brexit than we sometimes appreciate.
Who is Dr Tedros?
Born in Asmara in what is now Eritrea in 1965, Tedros Adhanom Ghebreyesus began his career in the 1980s fighting malaria epidemics. He studied epidemiology at the Danish Bilharziasis Laboratory (DBL) and Umeå University in Sweden and gained a PhD in Community Health. In 2005, when he became Minister of Health, he implemented a massive but cost effective malaria control programme with the result that there have been no major malaria outbreaks in Ethiopia for the past 11 years. Under Dr Tedros as Minister of Health 2005-2012 Ethiopia also reformed and expanded its health system. It created 3,500 health centres, 16,000 smaller health posts and expanded the health workforce by 38,000 workers. Long term financing for this was put in place be expanding health insurance coverage. Dr Tedros then served as Ethiopia’s Minister of Foreign Affairs from 2012-2016, during which time he was Chair of the African Union’s Executive Council.
Dr Tedros was widely seen by his peers as being a successful, reforming health minister. He has also been an effective player on the international stage in bodies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Roll Back Malaria (RBM) Partnership, as well as the African Union. Dr Tedros lists as one of his key achievements that when he was Chair of the Global Fund and RBM Partnership, he secured record funding for the two organizations and created the Global Malaria Action Plan. This expanded international malaria eradication efforts beyond Africa to Asia and Latin America.
Besides being the first African to lead WHO, Dr Tedros will also be the first Director-General without a medical doctorate. There are some commentators who argue that you cannot properly understand health issues without medical training. These people are usually medical doctors themselves. Other see it as the flawed reasoning of a vested interest. Its like saying you cannot understand transport issues unless you have been a train driver or an airline pilot. Or arguing that the Minister of Agriculture should always be a farmer.
What does Dr Tedros’s election mean for Global Health?
The arrival of a new Director-General will have immediate implications for staff working at WHO’s headquarters in Geneva. There will be changes in the private office of the Director-General and the communication team almost immediately. Changes in WHO’s management structure and management team are also possible, though not inevitable, over the coming year of so. But in the near term, there will be continuity in WHO’s policies and priorities. Dr Tedros inherits a set of programmes, policy declarations and funding streams built up over many years. They cannot be changed overnight.
In the medium term, though, we can expect a change of priorities and emphasis. During the campaign Dr Tedro put access to universal health coverage at the centre of his agenda. As Director-General he is likely to champion the expansion of health infrastructure across the developing world. He is likely to prize long term work to expand provision of basic health care above short term initiatives to respond to the latest “health scare”. From the point of view of people in Africa and the rest of the developing world, this makes sense. They would benefit much more from having better basic health care in the long term than ad hoc initiatives to fight specific disease outbreaks. The problem is that 80% of WHO’s funding comes from donors who specify how the money is to be used. Most of these donors are the rich countries of North America, Europe and East Asia. Their agenda is often driven by self-interest: they want WHO to fight disease outbreaks in poor countries so that they don’t threaten the health of people in rich countries. Reconciling the agendas of the rich world and the poor world will be the biggest challenge the new Director-General has to face.