(Endorsement) Dr Tedros Adhanom Ghebreyesus is the best candidate for the World Health Organization Director General

By Peter Byass writing in The Lancet

As Sally Davies has already pointed out (1), the World Health Assembly will shortly meet to elect the next Director- General (DG) of WHO. Three candidates (Tedros Adhanom Ghebreyesus [Ethiopia], Sania Nishtar [Pakistan], and David Nabarro [UK]) were selected by the WHO Executive Board in January, 2017, for the final stage of the election. All three are well qualified and experienced in their own ways and all fulflil WHO’s established criteria (1). So the important issue for the world’s ministers of health, meeting in Geneva, Switzerland, will be deciding which of the three candidates could best lead the needed reforms at WHO while also protecting and enhancing the health of the world’s people.

Unlike Sally Davies, my conclusion on examining the attributes and potentials of the three candidates is that Tedros is the best candidate (2). I first met Tedros more than 20 years ago when he led the vector-borne diseases programme in northern Ethiopia. At that time, villages were being encouraged to construct rain- fed reservoirs to safeguard their water supplies. That was important, against the background of earlier devastating droughts and famines — but Tedros was concerned with what the health implications of large water bodies close to habitation might be. With support from the Swedish International Development Agency (Sida) and WHO, Tedros undertook a large-scale study of the effects of the dams — with the result that malaria was found to be seven times more frequent among children living close to the new dams (3). His PhD thesis based on this work, The Effect of Dams on Malaria Transmission in Tigray Region, Northern Ethiopia, and Appropriate Control Measures, which I had the pleasure of supervising at the University of Nottingham, UK, was an outstanding example of relevant operational research. Innovative techniques for the time, such as Global Positioning System mapping, were developed in this work (appendix). A lasting memory of that collaboration was Tedros’ innate ability to mobilise and inspire communities towards better health.

Not long afterwards, Ethiopia’s late Prime Minister Meles Zenawi appointed Tedros as Federal Minister of Health. Ethiopia was still at a stage where governmental institutions were transitioning from a repressive Communist culture, and nowhere needed reform more than the Ministry of Health in the second- largest sub-Saharan country. One of Tedros’ biggest achievements was changing the culture at the Ministry of Health into a can-do, will-do environment, which also empowered the Regional Health Bureaux. The number of serving health professionals increased seven times, staffing 3500 new health centres, as well as the creation of a new cadre of 38 000 health extension workers at 16 000 new health posts. At the same time, Tedros was encountering WHO and other international agencies not as an insider, but as a “client”. His determination to get effective support and solutions for Ethiopia’s major health problems was soon recognised internationally, leading to him serving terms as Chair of Roll Back Malaria and the Global Fund. Bill Clinton described him as “one of the ablest public servants I ever worked with” (4).

Later, moving from the Ministry of Health to the Ministry of Foreign Affairs was perhaps a counter-intuitive strategy for someone so passionate about delivering health care. But, at least in terms of preparing for the role of WHO DG, gaining experience of international diplomacy and negotiation was no bad thing. Tedros took leading roles in peace negotiations for neighbouring South Sudan, worked with ongoing difficulties in Somalia, and steered the UN’s Addis Ababa Action Agenda to its conclusion. Perhaps most tellingly, many Ethiopian diplomats around the world were hugely inspired by Tedros’ introduction of the same can- do, will-do culture at the Ministry of Foreign Affairs as he had already brought to the Ministry of Health — not least evidenced by the growing social media presence of the Ministry and its overseas missions.

How do Tedros’ experience and abilities lead me to conclude that he is the best candidate for WHO DG? WHO is fundamentally constructed around its Member States that it seeks to serve through technical support and assistance on health matters. Years of experience on the other side of the counter, as Minister of Health, is therefore a key attribute for the new DG. Africa is a key region within global health development and to make progress, African countries depend critically on getting good technical support. Thus, electing an African leader at WHO would send out an important message — hence the African Union’s official endorsement of Tedros. Ethiopia is not a permanent member of the UN Security Council, making it eligible by convention to provide the head of a UN agency, as explained recently by Andrew Mitchell, the UK’s former Secretary for International Development (5).

WHO faces challenges of funding, organisation, and credibility — leading to the current widespread consensus that reform is urgently needed. Tedros has the experience of raising and managing budgets in the billions for international organisations like the Global Fund, as well as for implementing health reforms in Ethiopia. The current health budget in Ethiopia is only marginally below WHO’s current global budget, even though one might argue that both are far too small. Tedros has turned around monolithic organisations with integrity and charm. He relates to people around the world, as evidenced by his approximately 225 000 followers on Twitter (@DrTedros). As the youngest DG candidate, he also has the potential to take the long-term view of WHO’s needs, and hopefully see through necessary reforms over a double-term tenure as DG.

This WHO election comes at a critical time not only for the organisation, but for global health and security in general. Outgoing DG Margaret Chan has spearheaded the concept of Universal Health Coverage (UHC), (6) but a major effort is still needed to achieve UHC implementations globally. Uncertainties around potential epidemics, in which WHO would need to perform better than it did with Ebola in 2014–15, (7) are a perpetual concern.

Nobody can foresee the future with certainty, but it is clear that WHO needs a new leader who has what it takes to inspire Member States, who can effectively reform and lead WHO and its large staff, and who can thereby contribute directly to improvements in people’s health on a worldwide basis. To me, Tedros is the best of the three outstanding candidates in these important respects, and I therefore urge Member States to vote for him.

I declare no competing interests. This content is solely my responsibility and has not been discussed with Dr Tedros or his campaign team.

Peter Byass — peter.byass@umu.se — Epidemiology and Global Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå 90187, Sweden.

FOOTNOTES:

(1) Davies SC. Dr David Nabarro is the best candidate for WHO Director-General. Lancet 2017; published online May 8. http://dx.doi. org/10.1016/S0140–6736(17)31255–2.

(2) Adhanom T. The Director-General that the World Health Organization needs. http://www. drtedros.com (accessed 7 May, 2017)

(3) Ghebreyesus TA, Haile M, Witten KH, et al. Incidence of malaria among children living near dams in northern Ethiopia: community-based incidence survey. BMJ 1999; 319: 663–66.

(4) Former President Bill Clinton commends Dr. Tedros during 2014 Opportunity: Africa conference. YouTube. May 7, 2017. https://www.youtube.com/watch?v=OpELK8pCu8c (accessed May 15, 2017).

(5) Mitchell A. The WHO failed on Ebola. With a future pandemic inevitable it needs reform. The Guardian (London), April 27, 2017. https://www.theguardian.com/commentis- free/2017/apr/27/who-failed-ebola-pandemic- reform-world-health-organization-dr-tedros- adhanom-ghebreyesus (accessed May 7, 2017).

(6) The Lancet. Universal Health Coverage — looking to the future. Lancet 2016; 388: 2837.

(7) Moon S, Sridhar D, Pate MA, et al. Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard- LSHTM Independent Panel on the Global Response to Ebola. Lancet 2015; 386: 2204–21.

You can read more about Dr. Tedros and his vision for a healthy world as #NextDG at #WHA70 on his website: http://www.drtedros.com/ — and follow along with his campaign on social media at Facebook.com/DrTedros.Official and on Twitter at @DrTedros. Sign up for the campaign’s newsletter `From the Desk of Dr. Tedros’ at http://bit.ly/2nGWtLm.