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September 2017 (Volume 95)
Lawrence O. Gostin
In May, the World Health Assembly elected Tedro Adhanom Ghebreyesus as its ninth Director-General (D-G), the first African to lead the World Health Organization (WHO) since its formation in 1948. Dr. Tedros faces a daunting task, with WHO facing a crisis of confidence after its much-maligned response to the West African Ebola epidemic. Does his leadership record bode well for the Organization’s future success? That success is vital to world health, as WHO alone has the international legitimacy to forge cooperative solutions to complex health challenges. Dr. Tedros’s record offers a sharp contrast between promise and peril for the Organization. As health minister for Ethiopia, Dr. Tedros forged unprecedented gains in population health; nevertheless, his country’s human rights record was abysmal during this same time period.
A Health Minister of Stature and Achievement
Dr. Tedros built a community health system that became the envy of Africa. His signature initiative, the Health Extension Program, trained and deployed more than 35,000 community health workers. He created thousands of new health posts, with nearly a tenfold increase in medical student enrollees, reversing one of the most severe health worker shortages in the world. Building Ethiopia’s human resources and reorienting its services toward community empowerment represent a powerful legacy.
While the vast majority of African governments reneged on the Abuja Declaration’s historic pledge of devoting 16% of the national budget on health, Ethiopia achieved that target during Dr. Tedros’s final year as health minister in 2012. He also worked skillfully with aid organizations, securing 41% of Ethiopia’s health expenditure from international assistance.1 This mix of innovative programming and external funding achieved vast improvements in health outcomes, including formidable drops in child and maternal mortality from 2000 to 2015 (59% and 61%, respectively). Ethiopia achieved a landmark, meeting the Millennium Development Goal for reducing child mortality, while nearly achieving the maternal mortality target.2 Yet, the country has a long way to go—for example, skilled birth attendance levels remain among the world’s lowest at 28% in 2015.3
Dr. Tedros has extensive experience on the world stage, having chaired boards at the Global Fund, the Roll Back Malaria Partnership, and the Partnership for Maternal, Newborn and Child Health. Having advised WHO’s senior leadership, he clearly understands the Organization’s culture and challenges. His first words as D-G were, “All roads should lead to universal health coverage” becoming WHO’s “center of gravity.” He promised to tackle systemic deficiencies in WHO’s own human resources and transform its governance.
WHO is currently in an unvirtuous cycle. Member states have lost confidence in the organization, while donors refuse to fully fund it, leading to additional dysfunction and failure. If Dr. Tedros is to succeed, he must regain badly eroded trust—not only among member states, but also among civil society. Nongovernmental organizations have fought for full funding of the Global Fund, the Gavi Alliance, and The US President’s Emergency Plan for AIDS Relief (PEPFAR). But they have shown little appetite for supporting WHO. That negative perception could be reinforced if Dr. Tedros does not rise to the next challenge—a full-throated defense of human rights.
Central Committee of the Tigray People’s Liberation Front: Human Rights
Dr. Tedros uniquely stands out among the 9 WHO D-Gs for his high-level position in a repressive government. He was Ethiopia’s foreign minister and then special advisor to the prime minister after his term as health minister, serving on the dominant party’s and ruling coalition’s key leadership committees. In Ethiopia’s parliament, the ruling coalition outnumbers the opposition 547 to 0. Human Rights Watch reported that the government is responsible for torture, the disappearance of dissidents, and a “government stranglehold” over the media. A 2009 law “severely curtails . . . independent nongovernmental organizations,” and hundreds of people have been killed in recent protests.4 The infamous record within this African nation raises concerns within the continent and beyond.
The WHO election brought drama with last-minute press disclosures that during Dr. Tedros’s time as health minister the government failed to honestly and openly report several cholera outbreaks, despite United Nations confirmation of the disease.5 The government acknowledged only the presence of “acute watery diarrhea” despite the fact that the WHO International Health Regulations (IHR) (2005) established a vital global health norm of prompt and accurate reporting. The country’s reasons for noncompliance mirrored those of many other countries—a mix of concerns about trade (agricultural exports), tourism, and international prestige. While failing to honestly report a serious health condition may be common, it is nonetheless wrong and demands redress.
It would be unfair to blame Dr. Tedros for the Ethiopian government’s human rights abuses. He was probably under enormous pressure to support the government, even if he vigorously pushed back against abusive policies. But Dr. Tedros now represents the community of nations, without special allegiance to his home government. His new responsibility is to defend WHO’s highest constitutional norm, the right to health. It isn’t easy for a D-G to speak truth to power when he is so reliant on member state financing. Yet, breaking WHO’s unvirtuous cycle requires him to speak out publicly in defending WHO’s core values.
As head of WHO, Dr. Tedros bears responsibility for assuring state compliance with the IHR to advance global health security. A brave statement in defense of the right to health, as well as civil and political rights would auger well for his and WHO’s future. He will also need to publicly call out governments that fail to honestly and accurately report novel infections.
Optimism for the Future
There is reason for optimism. Dr. Tedros was the most vocal D-G candidate in defending the right to health. The rights-based universal health coverage that Dr. Tedros supported should draw enthusiastic support from liberal democracies as well as civil society. But WHO cannot succeed without the institutional building blocks for universal health coverage and full organizational effectiveness. Universal health coverage needs to expand beyond basic health care, with a robust vision of the right to health, including accountable, participatory health systems, paying particular attention to the needs of poor and marginalized populations. A key priority should be to infuse equity throughout the health system, from community to global levels. His emphasis on the rights of women, health security, and climate change are the right priorities. His promise to mainstream human rights throughout the organization would be transformative. Understanding the discrimination against the LGBT community that is common in Africa, his robust support for LGBT rights would have deep symbolic resonance on the continent. It would also gain the enthusiastic support of UNAIDS and AIDS advocacy organizations.
Dr. Tedros assumes his position as WHO’s D-G with considerable goodwill among member states. He has a historic opportunity to restore WHO to a position of global health leadership. The pathway is clear: institutionalize human rights throughout WHO and the global health system; demand and develop mechanisms for WHO Secretariat and member state transparency and accountability; and enunciate an unwavering commitment to the public’s health over politics. Too much is at stake for him to do otherwise. And if he does deliver on these pledges, all of WHO’s stakeholders—from governments and major foundations to health and human rights advocates—must do everything possible for him to succeed.
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
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