New world health boss has a great record as a swift innovator in Africa
Former Ethiopian minister faces challenge of fighting epidemics in face of Trump’s medical research cuts
The first African to lead the World Health Organisation (WHO) as its director-general, Ethiopia’s Tedros Adhanom Ghebreyesus, started on July 1 and hit the ground running. Using Twitter to effect (he has a considerable following), he declared that universal health coverage, health emergencies, women’s, children and adolescent health and the health effects of climate and environmental change will be priorities under his leadership.
The man knows his onions and has his feet on the ground. He comes to the job with a widely acclaimed record as a dedicated innovator and reformer, illustrated no less by measures he introduced to drive a 30% decline in child mortality when he was Ethiopia’s health minister.
His record in combating infectious diseases is exemplary. He is well-qualified, chaired the Global Fund between 2009 and 2011, attracted many awards and was once identified as one of 50 people who would change the world.
Tedros has quite a job. Under his predecessor, Margaret Chan, the WHO did many things reasonably well but moved at a dolorous pace during the West African Ebola outbreak, taking far too long to declare a public health emergency of international concern.
Under her, the WHO did not want to offend the overwhelmingly Catholic countries of South America by being more assertive in providing contraceptive advice to women during the Zika outbreak, which it should have, given the medical consequences.
In response to Yemen’s cholera outbreak, Tedros moved swiftly, accepting $66.7m from Saudi Arabia’s minister of state, Ibrahim al-Assaf, to help combat the highly contagious bacterial cholera, which is caused by poor access to clean water and sanitation. There is a certain irony in the fact that the 14.5-million Yemenis who have no access to the basics are in this situation because of an intractable war that involves the Saudis.
The cholera outbreak is severe. It has spread to 21 of the country’s 22 provinces, infecting 269,608 and killing 1,614 people, the latter figure larger than all the cases reported to the WHO worldwide in 2015.
The UN Children’s Fund’s Anthony Lake said the world was facing its worst cholera outbreak, with an average of 5,000 cases a day. Of the dead, a third — more than 500 — were children. Almost 19-million people, more than two-thirds of Yemen’s total population, are in need of humanitarian assistance.
It is about to become worse. On July 11, the UN announced it was suspending Yemen’s planned cholera vaccination campaign, reversing a decision made a month ago. As the New York Times observed, the disease’s rampant spread and the ravages of war there would render such an effort ineffective. Tedros briefed the UN Security Council on the catastrophic situation as a result.
Disease outbreaks in war-torn countries such as Yemen, Syria or South Sudan are examples of what are known as multiple-hazard risks, where severe conflicts in human affairs (or natural catastrophes such as earthquakes) have epidemic or pandemic consequences. But there are also infectious disease risks that come with the failure of countries to detect, prevent, mitigate and treat disease because of a lack of investment in health personnel, biosurveillance and other technologies and health systems.
By making universal access to healthcare the WHO’s first priority, Tedros is telling individual countries that do not invest in their countries’ health systems to remedy this, or for countries such as SA, which spends the second-largest budget item on health but delivers pitiful outcomes, to sort themselves out with better governance and management.
A stuttering, uncoordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands was followed by one of the most successful global partnerships to stem an international health crisisMark Siedner and John Kraemar
Health is a public good that cannot be left entirely to market forces, but public health systems must be subject to exacting performance requirements in turn.
It will no doubt take time for the health performance of countries to improve. But it is in everyone’s interests that there is a global back-up for emergencies. As Tedros pointed out in his speech to the Group of 20 (G-20) assembly of leaders on July 8, "pandemics of infectious and other threats to health, such as antimicrobial resistance, transcend borders and national interests, so vulnerability for one is vulnerability for all of us. And viruses actually do not know or do not respect borders."
This is why the Global Health Security Agenda was set up in the first place, to help countries comply with the WHO’s 2015 International Health Regulations. Launched in February 2014 and given impetus by the West African Ebola outbreak that killed 11,312 people, the agenda has grown into a co-operative enterprise that involves more than 50 nations, international and nongovernmental organisations.
"A stuttering, uncoordinated early response, which exposed the overwhelmed public health capacity of the region and claimed the lives of thousands was followed by one of the most successful global partnerships to stem an international health crisis," observed Mark Siedner and John Kraemar in the Lancet.
The agenda’s interventions, framed by the Atlanta-based Centers for Disease Control and Prevention, are wide-ranging and focus on prevention (antimicrobial resistance, animal-borne disease, biosafety and biosecurity and immunisation); disease detection (real-time surveillance, laboratory systems, disease reporting and health-workforce development); and responses (establishing emergency centres, linking public health with law and multisectoral rapid response and advancing medical countermeasures and personnel deployment).
The US Trump administration has identified the Centers for Disease Control and Prevention for budget cuts. The organisation’s former director, Tom Frieden, estimates it will lose $1.8bn from its $7bn budget, a 25.7% cut.
There is a proposal to shift the organisation towards block grants, generally viewed as naïve and short-sighted. Block grants for tuberculosis (TB) programmes gave rise to deadly outbreaks of drug-resistant TB that cost more than $1bn to deal with. Georgia’s public health commissioner, Brenda Fitzgerald, was recently appointed to run a Centers for Disease Control and Prevention squeezed by President Donald Trump’s narrow-minded bean counters.
It is in response to the Trump administration’s nationalistic insularity that Tedros made a strong pitch to the G-20 for "sustainably financing the global health security system". Importantly, he remarked that "ensuring a guaranteed level of contingency financing for outbreaks and emergencies would be a great start".
Tedros made the health effects of climate and environmental change a WHO priority. As health minister battling the effects of climate change on disease vector controls, he persuaded Ethiopia to invest heavily in its National Meteorological Agency.
Though he was criticised for how he managed the antimalarial and anticholera campaigns in Ethiopia, he understood well enough that climate change was having a direct effect on the ecosystem habitat of the malaria-bearing mosquitoes that afflict the country during the wet seasons.
He also understood that no one government agency – or one government — can tackle such worldwide issues alone. On this score, Tedros will find strong support from US science institutions and their leaders, as Trump and his merry band of climate-change denialists are blowing against the wind.
• James is a visiting professor at Columbia University’s Medical Centre and School of International and Public Affairs.