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June 9, 2017

Garrett on Global Health

Dear friends and colleagues,

On May 23, the World Health Organization (WHO) elected a new director general (DG), who will take the helm at the institution on July 1. Ethiopia's Tedros Adhanom Ghebreyesus is the first African to lead the WHO and also the first nonphysician, which could prove to be an even greater challenge in steering the MD-dominated organization than its European bias. Dr. Tedros, as he is called, has a PhD in community health. In this photo I snapped of Tedros during his first press conference after the election, the fifty-two-year-old former minister of both health and foreign affairs seems ebullient. 

But there are troubles ahead for Tedros.

The Election

Tedros was one of six declared candidates for the DG position in the WHO's first genuine election. Since 1948, all previous DGs had been selected by the institution's thirty-four-member executive board in a secretive process that has been rife with corruption. To bring greater credibility to the process and increase the WHO's influence in the global health community, the entire election procedure was changed. All six candidates campaigned vigorously, making their cases to the executive board in its annual Geneva meeting in January. The board determined that three candidates—Tedros, Britain's David Nabarro, and Pakistan's Sania Nishtar—clearly led the pack, and they were granted permission to campaign for the votes of all 194 nations that are members of the assembly. For more than four months the three zigzagged the globe, visiting everywhere from tiny Pacific Island nations to mammoth countries such as the United States, China, and India.

In the lead-up to the election, I wrote in Foreign Policy about what was at stake for various constituencies in the global community.

By the time the Seventieth World Health Assembly opened on May 22, the electioneering evidenced many of the trappings of a typical high-level campaign in a Western democracy, including professional campaign staffing, social media messaging, last-minute rumors and mudslinging, speeches, handshaking marathons, and last minute rabble-rousing fetes. The election was held on May 23. According to the voting rules, each country was limited to four individuals inside the assembly hall in the Palais des Nations, where all emailing, tweeting, and texting was strictly verboten. Locked into the hall, the delegates for the 186 nations that qualified to cast written ballots—by virtue of being up-to-date on their WHO dues and being physically present in Geneva—cast three rounds of votes while hundreds of media and assembly attendees milled about outside, hoping for news. The new rules dictated that a candidate had to win a 66 percent majority, which Tedros (who led every round) achieved on the third vote, handily defeating second-place Nabarro. The votes were cast by secret written ballots, placed inside boxes and hand counted by WHO officials.

It may be some time before anyone can sift rumors from facts to determine whether the new election process eliminated the reviled corruption seen in past DG selections. But the debates, publications, and campaigning certainly elevated discussion of the problems facing the WHO and global health in 2017, problems that will loom over the Tedros's five-year term. Although the three candidates showed few policy differences during campaigning in 2016, by election day their differences in both substance and style were clear.

In his preelection speech to the assembly that I witnessed, Tedros said that "all roads should lead to universal health coverage." He noted that "no one should elect me because I am African. . . . But rather, because I built a health system [in Ethiopia] and I built a partnership."

Nabarro, who led the UN multiagency response to the 2014 Ebola outbreak in West Africa, was blunt about the lackluster WHO reaction to the epidemic, which forced the United Nations to step in. "The WHO could and should have acted earlier," Nabarro told the assembly. "We cannot sugarcoat it." In addition to creating a fast-acting outbreak response, Nabarro argued, the WHO should "guarantee accessible health care for every person on this planet." To that end, Nabarro vowed, "my goal is that every ministry of health feels that WHO is there for them."

In her final remarks, Pakistan's Nishtar remarked on "integrity: the bedrock of my campaign." Had she won, Nishtar would have been the first WHO leader with a background in civil society leadership, having founded her own nongovernmental organization (NGO), Heartfile. In her comments, Nishtar emphasized the need for vast reforms at the WHO that would allow "more stakeholders" inside the agency, which has long held NGOs, humanitarian groups, and the private sector at arm's length. Alluding to rumored promises made by her opponents to garner votes, Nishtar told the assembly, "My hands are free to nominate and fill WHO positions. I will push reform. . . . We all know what the issues are in the United Nations system. In order to predict what somebody will do in the future, just look at their past. My hands are clean. I will put health over politics. I am offering you a new deal for health."

You Wanted the Job, Tedros

Since the 2014–2015 Ebola debacle, everyone running for DG, as well as the WHO itself, has struggled to identify the flaws that prevented a swift reaction to the Guinea, Liberia, and Sierra Leone outbreaks and to imagine an improved capacity to respond. Whether the dangerous microbe is Ebola, Zika, pandemic influenza, or something entirely novel, there will be more outbreaks, epidemics, and pandemics. Our armamentarium is weakening in the face of mounting microbial resistance. I recently signed a denunciation of the use of antibiotics as growth promoters in the livestock industry worldwide, which noted, "This sweeping change in meat production and consumption has had grave consequences for our health and environment, and these problems will grow only worse if current trends continue."

The world is increasingly demanding support to build health systems capable of addressing not only occasional outbreaks, but also the full range of medical needs, including cancer, cardiovascular diseases, complex traumatic injuries, and mental health. As I noted in an appearance on the new Humanosphere podcast, the mandates far exceed the WHO's financing and capacity.

After refusing to do so for decades, the World Health Assembly finally voted to increase dues to the WHO by 3 percent, but the increase is trivial. The assembly passed a two-year (2018 and 2019) budget of $4.4 billion, but little of this funding is actually committed by nations or existing in bank accounts. To separate fantasy from reality, the actual 2016 budget offers guidance. With help from documents released at the World Health Assembly and a new publication from Knowledge Ecology International, the figures break down as follows:

Total 2016 budget request: $2.17 billion

From assessment dues $0.44
From voluntary contributions $1.72
Contributed by
      U.S. government $0.324
      Bill & Melinda Gates Foundation $0.276
      UK government $0.134
      GAVI Alliance $ 0.075
Total from the top four voluntary donors $1.717


As I explained to Brian W. Simpson (who took this photo of Tedros and me), from the Bloomberg School's Global Health Now, the WHO not only lacks sufficient resources, but is also overly dependent on just four donors. The first, the U.S. government, may reduce its commitments to all of global health, as well as much of the UN system, in the September budget debate. During the World Health Assembly, the White House released its proposed 2018 budget [PDF], which called for enormous cuts in health and science, including:

  • 26 percent of State Department and U.S. Agency for International Development (USAID) global health spending;
  • 20 percent of Centers for Disease Control and Prevention (CDC) global health spending;
  • 11 percent of U.S. President's Emergency Plan for AIDS Relief (PEPFAR) spending on overseas HIV programs;
  • 18 percent of all agency spending on HIV/AIDS overseas;
  • 100 percent of funding for international family planning;
  • 44 percent of overseas malaria spending;
  • 26 percent of tuberculosis spending; and
  • 25 percent of spending on neglected tropical diseases.

These radical reductions in overseas health spending largely mirror the themes laid out earlier this year in the Donald J. Trump administration's so-called skinny budget [PDF]. These cuts are mirrored domestic reductions, including the gutting of biomedical scientific research, climate science, health care for poor children, the CDC, and the Food and Drug Administration. Leaked drafts of the House of Representatives' Republican budget scheme reveal even harsher plans afoot for scaling back global health and development spending.

The U.S. delegation to the World Health Assembly, led by Health and Human Services Secretary Tom Price, consistently emphasized health security, giving little public consideration to such things as universally accessible health care or HIV. As I describe in a CFR Expert Brief, Price told the assembly that the WHO needs "to pursue a focused response to global health emergencies. That must be its number one priority. We expect the next director general to prioritize such threats, including pandemic influenza." In another speech at the Geneva gathering, Price stressed: "Global health security is an absolute priority for the United States."

In 2016 the Obama Administration paid the WHO $324 million in voluntary funding above its assessed dues. It seems likely that sum will be seriously reduced in 2018, perhaps by as much as half. The third-largest donor, the UK government, will have its hands full with Brexit negotiations over the next two years. A stunning 759 treaties, both bilateral and multilateral, will require renegotiation during the Brexit process, affecting dozens of issues including trade, regulation, food, and agriculture. Many of these treaties affect trade in pharmaceuticals and medical supplies, safety standards for medicines and food, and the UK role in foreign aid earmarked for global health. It would be decidedly unwise to forecast today how those matters are likely to be settled, or to count on a continued $134 million WHO contribution from the United Kingdom.

The other two major WHO donors are focused on one issue: polio eradication. In my CFR Expert Brief I detail how woefully dependent the agency has become on polio funds, which are used for most WHO salaries in the African region, the epidemic response budget, and dozens of programs far-flung from the final eradication battlefront in Afghanistan and Pakistan. With only five polio cases identified to date in 2017, eradication seems tantalizingly close: at the assembly it was much discussed as a realistic target for 2019. It is unclear whether GAVI, the Bill & Melinda Gates Foundation, Rotary International (which donated $53 million to the WHO in 2016), and other donors will remain heavily committed to the WHO after polio is eradicated.

The Pharma Fight Continues

The most vigorous debate at the World Health Assembly concerned a report [PDF] from the WHO secretariat titled "Addressing the Global Shortage of, and Access to, Medicines and Vaccines." The document linked patent-based production to high prices, shortages and supply diversions, and fraud and counterfeiting in the global market, noting that all nations, rich and poor alike, are experiencing the pain.

The report called for nations to track manipulation of global markets, fight on behalf of generic manufacturing, and identify market distortions that fail to follow classic supply-and-demand patterns. For example, recent outbreaks of cholera and yellow fever have generated demand for millions of doses of vaccines, but supply has not followed because remuneration to manufacturers is too low; the yellow fever vaccine costs just 27 cents.

Debate in the assembly was contentious. Doctors Without Borders (also known as Medecins Sans Frontieres, or MSF) pushed for strong links between patent regimes and excessive drug pricing. After hours of national statements and counterstatements, the divide split the United States and India, prompting a recess to allow the two nations to privately hash out an agreement. In the end, the assembly agreed to table the entire pharmaceutical discussion, leaving it to the WHO's executive board to discuss the subject in January 2018. As the Indian delegate told the assembly, "We have reached consensus to continue discussion." Brazil complained that medical shortages are not the same as access to medicines. National policies may maintain a steady supply of drugs, but their pricing could render the medicines inaccessible to most of the population. "But if we must," the Brazilian delegate said, "We will mix the issues. We cannot escape the discussion as government budgets get blown out of proportion because of health costs."

Ebola in Congo and Political Dynamite

In late April, an individual suffering from what was eventually diagnosed as Ebola stumbled into a clinic in the remote Bas-Uele region of the Democratic Republic of Congo (DRC). On the eve of the World Health Assembly, the new WHO health emergency program was, as I wrote, put to its first real test.

The DRC Ebola outbreak is located in one of the most dangerous places on the planet. It is remote, with few services or roads, surrounded by dense rain forests. And bad as the Ebola virus is, the Likati hospital district of Bas-Uele is rife with peril, surrounded by one of the world's worst refugee crises and explosive violence.

By June 2, the Ebola outbreak [PDF] had sickened several people, killing at least four, but remained within the Likati district of Bas-Uele. A scientist who has worked in the area told me it is traversed almost exclusively on foot, as there are no dirt roads, much less paved ones, and people rarely leave the immediate confines of their villages—a factor that likely limited spread of the virus.

Though the outbreak was originally thought to be larger, laboratory analysis has, as this carefully worded WHO statement puts it, been confined. The DRC government and the WHO are cautiously optimistic that the outbreak has been controlled and threat of Ebola eliminated. However, far from the Bas-Uele DRC outbreak, a single case of Ebola was reported on June 5 in Gulu, Uganda—an area that has experienced several outbreaks over the last two decades.

First identified in 1976, when the DRC was known as Zaire, Ebola has sparked at least seven outbreaks in the country. These outbreaks were always in rural areas that were difficult for humanitarian aid to reach, but the isolation had benefits as well: because it was tough for local people to leave, they were less likely to carry the virus with them to larger population centers.

In contrast, the 2014 epidemic thousands of miles away in Guinea, Liberia, and Sierra Leone marked the first urbanized Ebola crises, hitting cities with international airports. The flubbed, slow response to that outbreak has spawned a long list of reforms throughout the international health system. There are three hundred thousand doses of an experimental Ebola vaccine stockpiled, ready to be put to use, though the DRC government did not approve their use in Congo until May 30, and the vaccine may not be put to use in this outbreak.

But there is a lot more to contend with around Likati than a deadly virus, including no decent roads or airports and nearly nonexistent public health infrastructure.

The Bas-Uele province abuts the Central African Republic (CAR), where a gruesome 2013 civil war has recently revived and rival militias battle over control of natural resources. The Basse-Kotto and Mbomou provinces of the CAR lay just across the Mbomou River from the Congolese area now effected by Ebola. According to Oxfam America, 60 percent of the territory in those CAR provinces is controlled by rival militias.

The Norwegian Refugee Council has pleaded for other donors to provide $2.2 billion in urgent aid to forestall famine and further violence in CAR, but a mere trickle of a few million dollars is all that has materialized, the council says. Worse, the CAR and its DRC border area are so unstable that humanitarian relief convoys and activities are routinely attacked, and five civilian aid workers have been murdered over the last eighteen months.

Recently, violence in the town of Bangassou in Mbomou province has reached a catastrophic level, sending thousands of refugees across the river into Bas-Uele. The United Nations' ten-thousand-strong peacekeeping force has come under fire, and six soldiers were killed last week. According to the UN High Commission of Refugees, more than 103,000 CAR civilians have taken refuge in the DRC, mostly in the Bas-Uele province.

Even as refugees pour from the CAR into the DRC, another civilian tidal wave is coming from war-rife South Sudan into the CAR, filling the entire Mbomou River region with a steady flow of misery. Famine looms over 4.9 million people in South Sudan, with 100,000 at immediate risk of starvation. Along the DRC-South Sudan border sits Nzara, where U.S. military personnel from U.S. Africa Command are positioned. When Ebola first appeared in 1976, its largest epidemic was inside what is now called the DRC, but a second epidemic raged simultaneously in Nzara, followed by another in 1979. Both the human and bat populations in the area have historically tested positive for the virus.

The border conflicts and waves of refugees might be tolerable if the government of the DRC was stable and committed to the best interests of its people. But it is not. May 16 marked the twentieth anniversary of ruthless control of the capital, Kinshasa, by the Kabila family. When I was in the country during the 1995 Ebola epidemic, longtime dictator Mobutu Sese Seko controlled the nation. Two years later, Laurent-Desire Kabila led a march on Kinshasa, seizing control of a nation that has been locked in various states of rebellion and civil war ever since [French]. Following Laurent-Desire's death, his son, Joseph Kabila, took power in 2001. Despite widespread disdain for Kabila and his completion of the constitutionally limited two terms in office, the leader has refused to step aside or to set a firm date for democratic elections. Amid widespread concern that Kabila is maneuvering to retain power and serve a third term, a constitutional crisis looms over Congo.

The World Health Organization and humanitarian organizations are now wading into this violent, politically hideous, refugee-filled environment, hoping to find all of the Bas-Uele people infected with Ebola and use vaccines, quarantines, and treatment to bring the outbreak to a swift end.

Given this situation, it seems all the more remarkable that the WHO dares to say the Ebola epidemic threat is passed. Peter Salama, the recently appointed head of the agency's health emergencies program, credits an unusually swift reaction inside Congo, coupled with the country's strong polio surveillance network, for triggering a rapid global response. He shared his timeline with me, which indicates that, in just one month's time, the first possible case appeared in a clinic, all tiers of governance were notified, laboratory confirmation was completed, and international responders were on the ground. It was, Salama told me in Geneva, "the fastest ever for Ebola. It shows we've learned a lot since 2014."


But, Salma said, the situation on the ground is so dangerous that "there was nowhere for our teams to stay and twenty thousand refugees arrived from CAR today, alone. We're beefing up security for the team and they will stay until we're sure the outbreak is over."

The situation has changed radically at WHO headquarters, as well. While there is still no central command for outbreaks, "we're getting there," Salama told me. "When I arrived it was all random. Reports were pouring in from all over the world and there was no way to judge threat priority. Today I can tell you truly what the priorities are."

The Big Men of Global Health

The Lancet asked me to review a book about the Rockefeller Foundation's former mastermind of global health, Kenneth Warren. It was an opportunity to examine how policies and institutions have been created, setting global goals that we still debate decades after their conception. All too often these targets have been set by white men living in Europe or the United States, deciding the health fates of billions of people living far from the shores of Lake Geneva (or Lake Washington).

In the end I found myself wondering how the lessons of Warren's dreams and failures might apply to today's kingpins of global health philanthropy, such as Bill and Melinda Gates, Warren Buffet, and Mark Zuckerberg.

Recent Work

Electing WHO's New DG: Laurie Garrett Q&A, Part I

Advice for Tedros: Laurie Garrett Q&A, Part II

A Change of Guard at the WHO

A Conversation With Laurie Garrett About the Road Ahead for the WHO

Disease Experts Reveal Their Biggest Worries About the Next Pandemic

Ebola Returns in Congo, a Test of 'Next Time'

Who's Going to Be the Next Leader of WHO?

When Big Men Ruled Global Health - A Cautionary Tale

Quoted in Washington Post
                Voice of America radio broadcast

My work is also the focus of a chapter in Richard A. Clarke and R.P. Eddy's new book, Warnings: Finding Cassandras to Stop Catastrophes. As the jacket copy describes it, "Millions of lives lost to catastrophes—natural and man-made—could have been saved by the advance warnings of experts. Can we find those prescient people before the next catastrophe strikes? Two CEOs and White House national security veterans reveal insider views of previous disasters, chilling insights on today's threats to mankind, and a prescription to protect us." In conjunction with the release of the book on May 23, the publisher also released posted a video conversation with me, Clarke, and Eddy. Check it out here.


Good reading,


Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations

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