World

Search for WHO DG: Trust is key, says ‘hands-on’ candidate Nabarro

By Peter Fabricius 20 May 2017

Margaret Chan will retire in July as World Health Organisation (WHO) Director-General after 10 years and for the first time, later this month the world’s premier health organisation will choose her successor by a vote of all 194 of its member states instead of just the 34 nations on the WHO’s executive board, representing six different regions of the world, as in the past. PETER FABRICIUS interviewed Dr David Nabarro, one of the contenders for the position.

“This is a job I’ve been training for all my life,” Dr David Nabarro says often in his energetic campaign to be elected the next Director-General of the World Health Organisation.

It’s a good campaign line but in his case it’s also plausible. He’s had vast experience right across the spectrum of medicine, from treating sick kids in Iraq’s remote Kurdistan province early in his career, to holding several executive positions as an administrator in international public health organisations, including the WHO itself and the United Nations (UN).

Margaret Chan will retire in July as WHO Director-General after 10 years and for the first time, later this month the world’s premier health organisation will choose her successor by a vote of all 194 of its member states instead of just the 34 nations on the WHO’s executive board, representing six different regions of the world, as in the past.

In January the executive board whittled down the short list of candidates from six to three; Ethiopia’s Tedros Adhanom Ghebreyesus – the frontrunner with 30 votes, Pakistan’s Sania Nishtar close behind with 28 votes and Nabarro, a rather distant third with 18 votes.

The results surprised most observers who had favoured French candidate Philippe Douste-Blazy, along with Nabarro and Tedros, to make the last three. Another European, Italy’s Flavia Bustreo was also knocked out.

Tedros has a Phd in community health. He has been Ethiopia’s minister of health and most recently of foreign affairs. One of his big advantages is that he has the official support of the African Union (AU), an organisation of 55 states and therefore, potentially, 55 votes. Nishtar is a cardiologist who ran an NGO that provided free heart treatment to those who could not afford it.

Nabarro’s last job was as special adviser to the UN Secretary-General on the UN’s 2030 Agenda for Sustainable Development and Climate Change.

The final three candidates resigned their jobs in January and began campaigning intensely.

Nabarro acknowledges that the competition is tough but still believes he’s best qualified for the top job in global health because on the one hand, he’s the only one of the three candidates with personal, clinical, hands-on experience of medicine and on the other he has the widest experience as a public health administrator, including in the WHO itself.

“I’ve been in international public health, really, since qualifying as a doctor 40 years ago,” he said in a recent interview in Johannesburg, about half way through a hectic world tour of some 48 countries to drum up support.

“Fifteen years of my early career was working at the frontline, in wars, or in community health programmes, development programmes and in research.” He has worked in Kurdistan on child health problems for the NGO Save the Children, as a child health officer in eastern Nepal “in a place you could only reach on foot” and elsewhere in South Asia, Africa and Latin America – over 50 countries in all.

Both his parents remained clinicians. But his own focus later shifted. “Right from the beginning, even though I was doing doctoring, I was interested in what was the underlying reason why my patients got sick. Was it poverty, was it lack of clean water, how did sickness link with the seasons, how did it link with the position of women?”

So he shifted from the “frontline” to the policy side of medicine in 1990 when he became director for human development in the British government’s Department of International Development, expanding Britain’s involvement in international health care tenfold.

He joined the WHO in 1999, heading its campaigns to roll back malaria, avian influenza and pandemics, and also doing a lot of work on environmental health.

In 2008 then UN Secretary-General Ban Ki-moon asked him to take on the world food crisis when food prices were rising very rapidly “and there were food riots all over the place. So I had to really transform the UN’s approach to food systems.”

He says he did the same for nutrition in 2010.

“In 2014 I was asked to lead the UN’s effort to repair a really difficult situation on ebola in West Africa which was not in a good space at all.”

In 2016 he was asked to manage the implementation of the UN’s just-adopted Sustainable Development Goals) and to help ensure the Paris climate agreement of 2015 was ratified.

“So I’ve moved from being a frontline worker, dealing with a lot of issues, directly with people, to being a policy person on a number of different issues…”

Nabarro said he was vying for this job because the world needed the WHO “probably… more than any of the other specialised organisations in the UN.”

Disease outbreaks

And that’s mainly because it is the primary line of defence for the world against infectious disease outbreaks. “And it didn’t do very well on ebola.” The WHO missed the start of the epidemic, was slow to pick it up and then slow to react.

It was widely felt the WHO had been “insufficiently impartial in blowing the whistle very, very loudly,” because it was too wary about the reactions from the governments of the West African countries where ebola had erupted.

Being able to point out that something is not right is key for the WHO and other agencies. “And it’s obviously hugely delicate when it comes to disease because no country gets big benefits from pointing out that they’ve got an infectious disease in their midst. So it’s very delicate stuff.”

This challenge for the WHO – which only wields “soft power” – is not so much about bluntly “telling truth to power”. It’s more about building up enough trust from the world’s national governments so they will listen when the WHO points out problems, “without having to go public.”

He said he had already had a lot of experience of doing just that, in south-east Asia with the outbreak of SARS (severe acute respiratory syndrome) and then with avian influenza.

“That’s what modern public health is all about… The trust is key.”

That trust was ever more important because of looming global health threats, including four different strains of bird flu which were moving round the world, any of which could form a pandemic;   zika which was spreading into Africa from Latin America; yellow fever which had spread from Africa into Latin America and was now threatening Asia and cholera which was bad in certain places like Ethiopia and Somalia right now.

He had dealt with cholera in Haiti where it had killed more than 9,000 people since 2010.

And then there is the HIV/AIDS epidemic which South Africa has suffered worse than most, (not least because the Thabo Mbeki administration denied the gravity of the disease, he does not have to add.) But he welcomes the “quite remarkable and extraordinary…huge shift” in South Africa, which is now leading the world in many aspects of HIV care, particularly with adolescents.

He singles out the Reproductive Health Institute of Wits in Hillbrow, “a global lead centre” in “cutting-edge research” and which he had just visited.

“So that area of dealing with disease outbreaks is my number one target for the WHO and I want to make sure it’s great at that.”

Other emerging health issues, other communicable diseases, HIV, etc

But he also wants the WHO “to be really good at helping all nations deal with the challenges of how to get good health systems, with accessible medicines, well-qualified personnel that really poor people, marginalised people, will use and benefit from.”

That’s especially hard for emerging nations, like South Africa, which have so many others budget priorities, like education.

“And really women and children are right at the centre of the health system.   Here in South Africa the particular issues faced by women and children include unfortunately a lot of HIV and sexual health challenges. They also include some of the infectious diseases you get in any poor country; diarrhoea and so on.”

And the flipside of HIV is tuberculosis, particularly multi-drug-resistant TB. This illustrates another growing challenge for world health, the emergence of pathogens which are resistant to commonly-used anti-biotics such as TB and gonorrhoea.

Non-communicable diseases

Another major health problem facing the new WHO director-general is non-communicable diseases which include diabetes, high blood pressure, cancers –and the newest one, mental illness “which we are more and more worried about…. right across the world”.

Nabarro says the WHO sets standards and implements them through others. Setting standards which are meaningful for all countries and partnering with them to ensure they do the job well is key to the WHO and the future. This is in line with the reforms proposed by new UN Secretary-General Antonio Guterres.

“So, in summary, I offer myself as a candidate with experience, with capability, who’s done it a lot in other places, a candidate who knows what happens at the local level and at the same time has been at the policy table. I’ve led many initiatives.

“I can raise money. I can work with the politicians and they know who I am. Given that WHO has faced a few problems in the last five to 10 years, I’m the one who can be trusted to lead it into the next phase.”

But what are his chances?

But if Nabarro seems well-qualified, professionally, won’t the politics count against him?

Though he entered the race later than others because the British government had been distracted by Brexit, he surprised many observers by coming third in the January “semi-finals” and some believe that indicates he has the momentum to secure the job later this month.

Mathias Bonk, a global health consultant, has been quoted as saying that European votes were divided among three European candidates in January and so Nabarro, the sole remaining European, would be much stronger in the final.

But he will potentially be up against much larger numbers of non-Europeans among the 194 electors this month, including the 55 African WHO members who are officially committed to backing Tedros.

He remains undeterred. He was to meet South African health minister Aaron Motsoaledi the day after our interview to seek his support as he believed South Africa was a very influential country. But why would South Africa vote for him rather than for the official AU candidate Tedros? Nabarro said he appreciated that there had never been an Africa WHO director-general before and so Africans might well feel it was their turn.

Nevertheless he would add that “the World Health Organisation really needs to have the best possible person for the job. And this is important for South Africa, it’s important for Africa, it’s important for the world. And this is not really an appointment that should be made because of a political calculus”.

He emphasised his belief that the WHO chief should be a person with hands-on clinical experience of patients – such as a doctor, nurse or midwife – which only he had, of the three finalists.

He would also tell Motsoaledi that if no candidate won the necessary two-thirds majority in the first round of voting and if Tedros was not one of the top two who made it through to the second round, he hoped South Africa and other African countries would then switch their votes to him.

He also pointed out that it would be a secret vote “so all sorts of things can happen”. “I think it is important that we don’t assume that just because the African Union has endorsed Tedros that all African nations will support him…” The election would not be officially organised on a regional basis so member states could vote for anyone, even though the candidates were seeking endorsements from organisations.

Nabarro also stressed that the WHO would not talk down to Africa if he were at the helm. Africa was “almost a laboratory of learning and practice” in health matters at the moment, with innovative work being down by both the private and public sectors.

“So we’ve really shifted from a world in which poorer countries in Africa, say, are being shown what to do by wealthier countries in Europe and America.

“It’s much more a question of sharing… examples from here or West Africa, showing other countries in the world how they can get multi-purpose workers to perform more activities at the local level or how they can link together work, as I saw it in West Africa on health, education, water and sanitation in a much more integrated way.”

As director-general he would “encourage this interchange and interplay and excitement about learning from each other. And not having it all go in one way”.

Though he is munching a meatless lunch, Nabarro says he is not a vegetarian. “But there are certain things I don’t do. I don’t smoke. Drinking alcohol I do in moderation. And other things that are known to be bad for my health, I don’t do.

“In the interests of full disclosure,” he adds, with a smile. DM

Photo: Dr David Nabarro speaks with  Maria Sibanyoni, a Programme Manager for the Women at Risk programme of the Wits Reproductive Health Institute(RHI) during a recent visit to Johannesburg.

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