What we know as WHO heads into historic election

In less than a week, the World Health Organization will be headed in a new direction.

Member states are converging in Geneva for the World Health Assembly on May 23 to cast their votes for a new director-general in what is considered to be a historic moment for the WHO. In part that’s because the world’s health leader will be chosen for the first time by secret ballots with equal voting share for all 194 member states. There’s drama in the uncertainty of whom among the remaining candidates might win: Tedros Adhanom Ghebreyesus, David Nabarro or Sania Nishtar.

But more consequentially, this election is widely seen as vital because the WHO is perceived to be falling far short of its ambitious name. Observers say a slowness to respond to the 2014 Ebola outbreak typified a litany of problems from under-funding to a sclerotic bureaucracy to a global health mandate almost impossible to implement.

The director-general, though bound by what member states want, still carries a weight of influence and authority in setting priorities, providing the right policies and guidance for important global health issues, and maneuvering a cadre of global health experts in addressing health threats and emergencies. He or she can choose to use the high-profile role to be an outspoken advocate, making the case for global health with publics around the world and pushing back on member states’ demands in order to control and reform the unwieldy agency.

Should the new director-general decide to shake up this organization — and all three candidates have pledged to do so in their own way — he or she will face an uphill task balancing both the internal politics of an organization where Geneva sometimes feels disconnected from its regional and country offices and the external politics of balancing its members’ national agendas with its global health mandate.

This election — with its emphasis on transparency and democracy — is meant to provide a platform to choose a talented and strong new leader capable of leading the WHO and its vital global role into a brighter future. But as the vote looms on Tuesday, there is no clear expectation of who will get to take on this challenge. Ethiopia’s Tedros Adhanom is seen by some as the front-runner since he received positive votes from 30 of 34 members of the executive committee in the shortlisting round in January and because of the endorsement of the 55-member African Union and the 79-member African, Caribbean and Pacific Group of States. But many countries are keeping their cards close and anything can happen with a secret ballot.

As the WHO enters the final few days of the contest one fact remains: its new director-general will be one of just three people. Below Devex examines where each of the candidates stands as the race nears its end.

Tedros’ high-profile endorsements up against controversial questions

Were the elections determined by Twitter followers, Tedros Ghebreyesus would win by an overwhelming majority, with 227,000 votes. The Ethiopian candidate has amassed 17,000 more followers in the past six months, according to Twitter Analytics. British candidate David Nabarro has garnered close to 3,000 followers in the same period, and Pakistan’s Sania Nishtar just over 1,000.

Yet popularity has its downsides. While Tedros may have the most high-profile endorsements and followers on social media, he also faces the most damning criticism.

Since the campaign kicked off eight months ago in Sept. 2016, several regional organizations and individuals announced their support for various candidates to lead the WHO. The African Union was quick to back Tedros, and in recent weeks, the African, Caribbean and Pacific Group of States, or ACP, came out with a resolution urging its members to support the Ethiopian’s candidature.

A number of African heads of states and senior officials followed, as did notable personalities in global health and international development. Louise Mushikiwabo, Rwanda’s minister of foreign affairs and cooperation, dubbed Tedros the “people’s director-general.” Nigerian billionaire and philanthropist Tony Elumelu said he is a “man known as a performer.” Hans Rosling, the late doctor-statistician who co-founded Gapminder, congratulated him on his candidacy and said he was “very suitable for the task” of director-general of the WHO.

Andrew Mitchell, a U.K. member of parliament and former secretary of state for international development, also made a surprise beeline for Tedros, whose leadership style of being “decisive but humble man” is “perfectly suited” for the role, he said. The former U.K. chief whip said David Nabarro, the U.K. official candidate, is a “good man” and a “fine international civil servant” with extensive public health experience, but stopped short of endorsing him for the WHO position.

Yet against that support, Tedros has faced persistent criticism centering on his role as the longest-serving health minister in Ethiopia. Some figures — especially among members of the Ethiopian diaspora — have argued he was complicit in that government’s human rights violations. Tedros has consistently attributed the accusations to Ethiopia’s young democracy.

But there have been other attacks too. Georgetown law professor Larry Gostin, who is also director of the O’Neill Institute for National & Global Health Law and an adviser to Nabarro, lodged a more concrete accusation recently, accusing Tedros of attempting to downplay cholera during his time as health minister.

The Ethiopian candidate called the act a “last minute smear campaign” by Nabarro’s camp, which he accused of a “typical colonial mindset aimed at winning at any cost.” Nabarro insisted he was not aware and did not authorize any such statement.

Tedros sees the mix of his public health background and political experience as assets in navigating the role of WHO chief, but the issue of his past role in government has become a hot topic of conversation publicly and in private.

Thomas Frieden, who was until recently the director of the United States Centers for Disease Control and Prevention, wrote to the New York Times in defense of Tedros. “Although not optimal, many countries report cholera to the World Health Organization as acute watery diarrhea, as Ethiopia has,” Frieden said in a letter to the editor, in response to the news article. “This allows reporting and response without laboratory confirmation, but in no way indicates that Tedros Adhanom Ghebreysus … is any less qualified to become director general of WHO.”

How Tedros’ high-profile endorsements will translate to real votes remains a question. The AU and ACP’s support is public, but they will have no way of guaranteeing the way their members will ultimately vote, especially when it’s in secret.

Nabarro’s track record and the geopolitical game

British candidate David Nabarro has the most on-the-ground and international experience, particularly when it comes to dealing with pandemics and difficult donor negotiations.

He was asked to lead the U.N.’s response to the Ebola outbreak that swept across West Africa in 2014, and has been a staunch defender of the WHO actions that eventually raised billions of dollars needed to fight the virus.

But Nabarro has met with less success in his current charge of leading the response to the U.N.’s response to the cholera crisis in Haiti, raising some questions about Nabarro’s ability to garner support for less popular issues. The U.N.’s $400 million multi-partner trust fund for the immediate and long-term response to the cholera epidemic in Haiti is severely underfunded, with just over $2 million as of April 2017.

Nabarro has acknowledged the difficulties in raising the U.N. appeal in various interviews. He has noted the need to find other means to fill the fund, particularly the compensation for those who fell victim to the disease, which was brought to the island by U.N. peacekeepers.

Some note a desire from many developing countries to elect someone from their own ranks — as well as the current fracas over Brexit — could put Nabarro at a disadvantage. But, on the other hand, the British government has given its full backing to the candidate, with both financial and human resources. His communications is handled by members of the Foreign Commonwealth Office, and the U.K. government has been the single source of financing for his campaign activities outside official WHO meetings.

Dame Sally Davies, Britain’s chief medical officer, has been very vocal of her support for Nabarro, whom she has repeatedly called the “best” and “most experienced” of the three candidates who has “worked within [WHO], alongside it, and also challenging it.”

“I believe that WHO is too important to have anyone other than the best person at its head,” Davies said in her endorsement letter for Nabarro to the top job at the U.N. health aid agency.

“For all our sakes, I hope that health ministers will bear this in mind when their nations cast their votes at the World Health Assembly.”

How far the U.K.’s support will get Nabarro is unclear. He is the only candidate left in the race coming from a major donor country; the U.K. is the second largest bilateral country donor to the WHO.

But one U.N. official told Devex that scenario whereby Britain’s contributions to the WHO became linked to support for Nabarro was unlikely. “I find it far-fetched that the U.K. would threaten to withhold or increase financing to WHO based on the outcome of the [director-general] election,” the official told Devex, requesting anonymity to discuss internal matters.  

“They see WHO as critical for global health, and a key part of the international system [and] are committed to a strong, results focused WHO,” the official added.

Nishtar’s academic warriors and the battle for relevance

To those who’ve followed her career, Sania Nishtar is a highly accomplished doctor and civil servant. She is a published author who has founded her own NGO, Heartfile, and has been invited to be part of several international groups and institutions.

Pakistan’s first female cardiologist, Nishtar — who is widely seen as trailing both Tedros and Nabarro — has gathered her own set of champions, mostly from members of the academe and those working in the area of noncommunicable diseases. Beatriz Champagne, executive director of the InterAmerican Heart Foundation, called for the Latin America and Caribbean region to come together to rally behind the “best possible candidate,” whom she thinks is Nishtar.

“Sania’s vision is one that acknowledges that the most pressing problems we face here in Latin America and the Caribbean and across the globe — NCDs, pandemics, climate related health, the ongoing challenges of infectious disease including HIV/AIDs and new threats such as Ebola and Zika,” she said. Champagne also welcomed Nishtar’s understanding of and respect for the Pan American Health Organization’s special status.

She has pledged to push for radical transparency at the WHO, beginning with her own campaign. “Dr. Sania's a straight talker, she's making no deals during the election campaign so that she can bring in the best people to address these challenges,” former WHO director Ruth Bonita told Devex.

“She's well positioned to rebuild trust because she has a history of transparency. The campaign finances testify to that,” said Bonita, who is now professor at the University of Auckland.

Nishtar’s pronouncements of not making deals during the campaign could be seen by some observers as the actions of a political neophyte, whose stand on principle may get her nowhere.

The Pakistani candidate, however, is well aware of what she’s doing. “I am playing “bad politics” by making no deals, because if I’m elected by member states, I believe that “bad politics” will bode well for “good governance,” she said in an op-ed for Devex. Transparency and accountability top Nishtar’s campaign pledges, and her plan is to take it further down to the selection of deputies and assistant director generals, if she ends up taking the helm of health aid agency.

The Organization for Islamic Cooperation has “welcomed” Nishtar’s candidature to the WHO position, but again, this does not in any way guarantee votes at the World Health Assembly.

Nishtar told Devex that while she’s honored by the support she’s received so far from member states across the WHO regions, she is “not branding [her]self as a candidate of any region or group.”

Unlike the movement that emerged during the U.N. secretary-general elections, the WHO race hasn’t seen a rally of support for the only remaining female candidate, perhaps because the WHO has had prior female leadership, including outgoing Director-General Margaret Chan.

Molly Anders contributed reporting.

Devex will be reporting live from the World Health Assembly in Geneva. Follow @devex and our reporters @AdvaSal and @JennyLeiRavelo ‏and subscribe to the Development Newswire for our coverage of #WHA70.