Why Barack Obama Should Lead WHO, And Why He Won’t

The 19th-century German doctor Rudolf Virchow, (known as the father of pathology) was also a tough politician. “Medicine is a social science,” he once wrote, “and politics is nothing else but medicine on a large scale.”

Global health, then, involves politics on a global scale. Next spring we will see the election of a new director general of the World Health Organization, chosen by all the member states of the United Nations, and it will be a very political choice indeed. But the health and even the lives of millions of people will depend on who is chosen.

Late in September, WHO announced that UN members had proposed six candidates. Four are Europeans, one is Ethiopian, and one is Pakistani. Two of the Europeans are senior WHO officials.

On Nov. 1 and 2, all the candidates will take part in a forum (not a debate) to be webcast on WHO’s website, where they will present their visions for the future of the organization. Early next year, WHO’s executive board will narrow the field to five, and then to three. The World Health Assembly will elect the new director general in May, and he or she will take office on July 1 when Dr. Margaret Chan steps down after two terms.

A critically underfunded agency

The winner will need to be experienced in public health, and also need to be a very effective politician. That’s because WHO, like many other UN agencies, has been essentially abandoned by the member states. They have long since failed to fund WHO adequately, exposing it to undue influence from non-governmental and charitable organizations.

The American Center for Disease Control and Prevention has a 2016 budget of almost $7 billion. To look after the whole world, WHO has a 2016-17 budget of just under $4.4 billion.

“Our work used to be funded entirely by assessed contributions from Member States,” WHO says on its website. “The amount each Member State pays is calculated relative to the country’s wealth and population. By 1990, voluntary contributions had increased to 54 per cent of total funds and now make up almost 80 per cent of WHO’s total income. While our budget has increased substantially — from US$1.4 billion for 1990-1991 to US$4.4 billion for 2016–2017 — the assessed contributions have remained stagnant at less than US$1billion.” Inflation since then has reduced the purchasing power of that amount to about $505 million.

As a result, WHO relies heavily on politically driven voluntary payments by member states and “non-state actors” — organizations like the March of Dimes Foundation, Oxfam and the World Council of Churches. These admirable but unreliable donors therefore tend to dictate WHO’s policies and actions.

It’s hard not to be cynical about the situation. Politicians intensely dislike publicity about their constituents’ health problems. Outbreaks of new diseases, which WHO pays increasing attention to, are especially unpopular: they make governments look both bad and incompetent.

The rage of Canada’s Liberals

The classic example is the 2003-04 SARS outbreak in Canada. As the mysterious new virus raged through Toronto hospitals, WHO’s then director general, Gro Harlem Brundtland, issued a travel advisory warning visitors to stay away. Prime minister Jean Chretien and the governments of Ontario and Toronto were furious at the economic and political damage that followed.

Toronto suffered economically for months, and finally paid for a Rolling Stones concert, admission-free, to let the world know it was again open for business. It’s a safe bet that Canada made a stink behind the scenes about Bruntman’s activism. Since 2006, the director general has been Canadian-trained Dr. Margaret Chan, who has led much more cautiously.

Not only are travel advisories far rarer, WHO presided over the importation of cholera into Haiti in October 2010. It was obvious from the start that the UN had brought the disease into the country, but neither the UN nor its agencies said anything about the origins of cholera. The disease has so far infected at least 790,000 Haitians (out of a population of 10 million). More than 9,300 have died, and the outbreak shows no sign of slowing.

Only in the last few weeks has outgoing UN Secretary-General Ban Ki-Moon finally accepted “moral responsibility” for the outbreak. But he still resists actually paying for the harm the UN has done to Haitians, and plans for controlling cholera depend entirely on donations from donors who are now very fatigued.

Similarly, when Ebola emerged in West Africa in 2013, WHO was very slow to declare it a “public health emergency of international concern.” The organization was reported to have worried about the economic and political impact such a declaration would have on Liberia, Sierra Leone and Guinea — all of them poor and unstable.

So while the Canadian president of MSF International, Dr. Joanne Liu, was calling early and often for Ebola action, Chan dragged her heels. By the time she did declare an emergency, Ebola was well entrenched. Before the outbreak ended, more than 28,000 persons caught it and more than 11,000 died.

WHO needs a political champion

More outbreaks of new and old diseases are inevitable, and the new director general will have to deal with them. It will take a brilliant global-health expert to anticipate such outbreaks and the resources they will require, and a brilliant politician to persuade the UN member states to provide those resources.

Even to become eligible for the job, the six candidates had to have political skills. But two of them are already senior WHO staffers; they may be too accustomed to WHO’s cautious culture. Ethiopia’s nominee may understand the problems of public health in poor countries, but may lack influence with the big powers. The same is true of Pakistan’s nominee, and Hungary’s nominee may suffer from the reputation of his increasingly authoritarian government.

My own preferred candidate would be Barack Obama, but his influence would terrify most UN member states, which tend to be poor and poorly run, and full of Obama admirers. As director general, Obama could demand and get the equivalent of regime change in countries suffering serious outbreaks. No despot in his right mind would consider such a person to head the World Health Organization.

Outbreaks tend to happen in poor countries with corrupt governments that prefer to spend more on weapons than on basic public health. But even Canada and the U.S. have a long way to go to achieve safe water on First Nations reserves and in poor communities like Flint in Michigan. All “advanced” nations tolerate serious health consequences from growing income inequality, and would reject policies that might annoy their 1%.

Obama, of course, will not be the next director general. Global health will be shaped in large part by organizations like the Bill and Melinda Gates Foundation and whatever NGOs can drum up the most money to steer WHO in a particular direction. WHO will help grind their axes, rather than attack urgent health threats that don’t concern the funders.

Old Rudolf Virchow had his limits; he didn’t believe in Louis Pasteur’s newfangled germ theory of disease. But he fully understood how politicians decide who gets sick and dies, and who stays healthy and lives. In a globalized world, disease is not confined to poor countries; Zika virus, for example, has spread from Uganda to Southeast Asia to the South Pacific to Brazil to Florida.

The next outbreak may be carried in a mosquito or tick or on the unwashed hands of a health care worker. But it will be an outbreak triggered by a politician’s action — or inaction.