Mission impossible? WHO director fights to prevent a pandemic without offending China

GENEVA—On 2 January 2019, Tedros Adhanom Ghebreyesus faced a life-or-death decision. The director-general of the World Health Organization (WHO) had spent New Year’s Eve in Bunia, Democratic Republic of the Congo (DRC), to boost the morale of staff fighting the second biggest Ebola epidemic ever. As he was getting ready to board a helicopter to Uganda, where he was scheduled to meet Prime Minister Ruhakana Rugunda, Tedros had to decide whether to bring along a young Congolese man named Charles Lwanga-Kikwaya.

The day before, a group of Ebola vaccinators was attacked by a group of young men and women—one of many assaults WHO staff has had to endure—and Lwanga-Kikwaya had been hit on the head with a large stone. His injury was serious, says Jeremy Farrar, head of the Wellcome Trust, who accompanied Tedros and examined the patient. “We quickly decided we either had to evacuate him or he was going to die,” says Farrar, who trained as a neurologist.

But the pilot refused to make a detour in a conflict zone; protocol dictated that Tedros, as a VIP, had to be flown to his state visit first. After a tense standoff with Tedros and several phone calls, the pilot relented and agreed to fly Lwanga-Kikwaya and the three international visitors to the nearest hospital. “It was interesting to watch Tedros’s style,” says Mike Ryan, head of WHO’s Health Emergencies Programme, who was also present. “Just quietly, determinedly saying, ‘No, we must leave with this man.’ Just that ability to be persistent but respectful.” “He’s stubborn, he won’t take no for an answer,” Farrar says. “You need that sometimes in a leader.”

Lwanga-Kikwaya survived and went back to work a few weeks later. Tedros, who is Ethiopian and the first African to head WHO, says he saw the confrontation as a test. “You cannot care about millions if you don’t care about a poor human being dying in front of you,” he says.

Today, Tedros is facing a far bigger challenge: a deadly virus that’s spreading from China around the world at an astonishing speed. On 30 January, Tedros officially declared the outbreak of the new coronavirus an international health emergency. Just the week before, the number of confirmed cases had exploded from 830 to almost 8000. Today, it has gone up to more than 40,000 cases in 25 countries. Flights have been suspended, cruise ships quarantined, and daily life in large parts of China brought to a standstill. Many scientists now assume the outbreak will develop into a full-fledged pandemic that could result in millions of infections and global disruption.

Tedros took office on 1 July 2017 with an ambitious to-do list: Reform WHO, strengthen evidence-based decision-making, highlight the health impact of climate change, and provide 1 billion more people with health coverage. But the epidemic of COVID-19, as the new disease was christened on 11 February, will overshadow all of his stated priorities, says Ashish Jha, a global health researcher at the Harvard T.H. Chan School of Public Health. How Tedros handles the crisis will shape not just his legacy, but the future of his organization, Jha says. “This is the moment! How things go over the next weeks and months will end up having a very big impact on how much the world values WHO.”

This is the moment! How things go over the next weeks and months will end up having a very big impact on how much the world values WHO. Ashish Jha, Harvard T.H. Chan School of Public Health

Yet the crisis has put Tedros “in a near-impossible situation,” says Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University. If Tedros wants WHO to stay informed about what’s happening in China and influence how the country handles the epidemic, he cannot afford to antagonize the notoriously touchy Chinese government—even though it is clear the country has been less than fully transparent about the outbreak’s early stages, and perhaps still is. Critics say that stance puts WHO’s moral authority at risk. “WHO has never faced such a fast-moving epidemic in a country that is quite that powerful and, in many ways, closed,” Gostin says.

And the epidemic comes on top of other challenges inside and outside WHO. Its budget hasn’t kept up with its tasks; misinformation about vaccines is spreading like wildfire; and leading politicians remain in denial about climate change, which could have profound effects on public health. Meanwhile, multilateral organizations like WHO are under fire from populists and nationalists. “All the global trends are against what WHO was founded for,” Gostin says. “The organization in the year 2020 is in the middle of a hurricane, hunkering down.”

Minister of health in Ethiopia

Tedros’s first memories of WHO are from a more hopeful time. Growing up in Asmara, then part of Ethiopia and now the capital of Eritrea, he saw posters advertising WHO’s global campaign to eradicate smallpox—a landmark public health feat accomplished in 1980. After studying biology and working in public health, Tedros received a WHO scholarship to study at the London School of Hygiene & Tropical Medicine.

He obtained a Ph.D. in community health, went back to Ethiopia to head a regional health bureau, and rose to minister of health. During his tenure, from 2005 to 2012, he is credited with building up a network of more than 40,000 female health workers in rural areas who dispense malaria drugs, immunize children, and care for pregnant women. Deaths from AIDS, malaria, and tuberculosis dropped by more than half on his watch. After 4 years as Ethiopia’s minister of foreign affairs, Tedros ran for the position of WHO’s director-general in 2017, with backing from the African Union.

Tedros put universal health coverage at the heart of his campaign. He first had health insurance, a luxury unavailable to him in Ethiopia, while studying in Denmark for 4 months in 1988. But he believes countries with few resources can offer universal coverage as well—even if they can only afford to offer basic care. “Half of the world’s population doesn’t have access to essential health services. I just refuse to accept that,” he says. Tedros beat the United Kingdom’s David Nabarro with support from 133 out of 186 member states in the final voting round.

Halfway into his first 5-year term, he occupies a spacious office on the seventh floor of WHO’s headquarters here. Presents from visiting dignitaries are on display: a traditional white hat from Afghanistan, a miniature wooden boat from Tuvalu, a little lighthouse from the Maldives. But when Science visited in December 2019, Tedros described a darker world. Violence was surging in the DRC; Ebola, almost under control, was spreading again; and health workers were still being attacked. The evening before, he had had a strategy call with U.N. Secretary-General António Guterres. “The most important thing now is security,” Tedros said.

A very different virus was occupying him, too: the misinformation about vaccines spread through social media. The day before, WHO had released the number of deaths in 2018 from measles, a disease for which cheap and effective vaccines exist: 144,000, a 14% increase from 2017. “This is crisis level already, and Facebook and Twitter or other social media groups should really understand this,” Tedros said. He said he has asked social media giants to do more to fight false information. (Today, WHO has started to work with the companies to flag misinformation and rumors about COVID-19 and direct users to WHO’s website.)

During his tenure so far, Tedros has been willing to take risks—and not just by taking a dozen trips to the Ebola battlefield. One of his first moves was to name Zimbabwe’s longtime dictator Robert Mugabe a WHO “goodwill ambassador.” Tedros says the suggestion came from African countries, where some still revere Mugabe—who died in September 2019—as an anticolonial hero, and that he had merely proposed him for the honor. “We only started the process,” Tedros says. After a massive backlash, he withdrew Mugabe’s name. “He corrected it immediately and that’s what leadership is about,” says Canadian health researcher Peter Singer, one of Tedros’s closest aides.

Fighting outbreaks is only one of WHO’s tasks, and until recently, it did so primarily by coordinating other organizations’ work. After the slow response to the West African Ebola outbreak of 2013–16 triggered outrage, the agency started to play a more active role. But to achieve its stated mission—“the attainment by all people of the highest possible level of health”—WHO’s primary job is to produce “norms and standards” that member states can implement, such as guidelines for malaria treatment, training materials for maternal health workers, or policies on opioid use.

Changing the DNA of the organization

As part of his reform plan for the organization—a top priority, he says—Tedros has appointed more women, made the top ranks more diverse, and created new departments, including one for “healthy populations.” As a former health minister, he has a keen sense of the practical needs of its member countries, says Bernhard Schwartländer, his Cabinet chief. Tasks such as updating WHO’s list of essential drugs were prioritized; others, such as the “policy framework on managing psychosocial consequences of radio-nuclear emergencies,” were dropped. “We are changing the DNA of WHO itself,” Tedros says. But the 72-year-old organization has a complicated structure with six regional offices whose heads enjoy considerable power. “WHO is a massive tanker. You cannot turn it around easily,” Schwartländer says.

To many in the ranks, the transformation seems a never-ending process. “He has significantly improved WHO’s core mission,” Gostin says. “But he has not been able to consistently bring WHO staff and partners with him, sometimes resulting in unrest.” Tedros acknowledges he has faced internal resistance. “People get a bit nervous when they see that you have this heavy change agenda,” he says.

Big job, modest budget “Assessed contributions,” or fees from member countries, make up a small part of the World Health Organization’s (WHO’s) budget and have remained mostly flat for 30 years. Donations have risen, but most are earmarked for specific goals. version="1.0" encoding="utf-8"? ’90– ’91 ’92– ’93 ’94– ’95 ’96– ’97 ’98– ’99 ’00– ’01 ’02– ’03 ’04– ’05 ’06– ’07 ’08– ’09 ’10– ’11 ’12– ’13 ’14– ’15 ’16– ’17 ’18– ’19 ’20– ’21 0 1 2 3 4 $5 billion Donations Assessed contributions WHO biennial budget Assessed contributions Earmarked donations Non-earmarked donations Sources of the 2018–19 budget (%)* 17 81 United States Bill & Melinda Gates Foundation GAVI United Kingdom Germany Other United Nations World Bank European Commission Rotary International Japan 15 13 8 7 4 5 4 3 3 3 35 *data up to 7 January 2019 2

One move that gets universal praise, however, is the creation of the position of chief scientist. “This is a really important signal,” says Ilona Kickbusch, a global health expert at the Graduate Institute of International and Development Studies. “Science is the bedrock of everything we do here,” says Soumya Swaminathan, an Indian pediatrician who has taken on the role. She says her department will focus on identifying research gaps; she has also launched committees to look at the ethics of gene editing and artificial intelligence in medicine and public health.

To many outside observers, what matters most is whether WHO will see an increase in its $2.5 billion annual budget, most of which does not come as “assessed contributions”—essentially countries’ membership fees—but as donations from countries or other donors (see graphic). They often earmark their contributions for specific projects, such as eradicating polio, which limits WHO’s ability to set its own priorities. Tedros also acknowledges the risks of depending on a few large donors. “If one of them refuses to continue funding, WHO could get into a serious shock,” he says. “It’s like a country which is dependent on oil.” So far, countries have resisted plans to significantly raise the assessed contributions. “I’m very positive about the changes that have happened, but a part of me wonders why that has not translated into a lot more funding and a lot more support,” Jha says. But Tedros points out that WHO has just developed an “investment plan” to attract new donors, and there have been some small increases in donations.

In the December conversation with Science, Tedros emphasized that disease outbreaks are a constant concern. “If there is a major outbreak, it’s not just a health problem. It can have economic, political, and social impact,” he warned. He did not know at the time that the biggest emergency of his career was already brewing in Wuhan, China.

Bending over backward

Two months later, WHO is in full crisis mode. Tedros and his top aides meet every day to discuss the grim developments. Journalists from around the word call into daily press conferences, usually with Tedros himself behind the microphone. The fight against Ebola had taught him a clear strategy, he said at one of these briefings: Fight the disease at the source and try to keep it from gaining a foothold elsewhere. “Focus on the epicenter,” Tedros said. “If you have several epicenters, it is chaos.”

But the fact that the epicenter is in China complicates that task. Tedros has bent over backward to stay on friendly terms with the emerging superpower. He flew to Beijing to meet with Chinese President Xi Jinping on 28 January and praised the Chinese government for its efforts to fight COVID-19—even though the country waited weeks before allowing officials to inform the public about the outbreak.

Tedros says his visit to China led to three important agreements: to fight the virus hard at its source, to share data, and to let an expert mission from WHO visit China. Yesterday evening, he saw off the mission’s advance team at the Geneva airport. In a call to Science afterward, Tedros defended China’s actions. “We appreciate the interventions they are taking,” he said. “They are doing it not only for their own country, but for the rest of the world.” He said a review at some later time would assess whether China’s actions were evidence-based and reasonable. “We don’t want to rush now to blaming, we can only advise them that whatever actions they take should be proportionate to the problems, and that’s what they assured us.”

For some, that strategy verges on appeasement. For instance, Tedros has joined the Chinese government in criticizing other countries for closing their doors to travelers from China, but has remained silent about the fact that China has closed off entire cities and penned in tens of millions of people, a measure some scientists believe may not help much and infringes on basic human rights. “I absolutely believe these measures should be called out, both for their human rights implication and their very limited public health impact,” says Alexandra Phelan, a global health law expert at Georgetown’s Center for Global Health Science and Security. But, she adds, China’s cooperation is so critical that she can see why Tedros might not speak out. “I just worry what it means going forward.”

Some go further. An online petition asking Tedros to step down has garnered more than 300,000 signatures. But Jha disagrees. “To take on China in some aggressive way in the context of this, I’m not sure that would have been helpful,” he says. “I think Tedros has been pretty masterful at pushing China, engaging with China.” Farrar says China has done reasonably well so far in a difficult situation, but the country should release more basic epidemiological data and viral sequences quickly. “To me, those are the two big gaps because those two allow you to track the epidemic,” he says. Tedros urges patience because China is overstretched. “So we get some information, we may not get other information. It may not be complete. But we understand that.”

Still, the epidemic has clearly shown the limits of the agency’s influence. The 30 January declaration of a Public Health Emergency of International Concern (PHEIC) is a case in point. Widely covered in media and perceived as an important step—although critics say it came too late—the declaration is largely symbolic. A PHEIC allows WHO to recommend for or against travel restrictions, and countries are supposed to follow its lead. But many, including the United States, have ignored Tedros’s recommendation against travel restrictions and have closed their borders to travelers from China. A PHEIC “gives more moral authority to WHO,” Jha says—but the agency has no power of enforcement.

“A very emotional man”

In October 2018, on a stage at the World Health Summit in Berlin, Tedros was asked about the third of the United Nations’s 17 Sustainable Development Goals (SDGs) for 2030: “Ensure healthy lives and promote well-being for all at all ages.” He told the audience a story about Hassab al Karim, a boy he had met a few days before in a cardiac clinic in Khartoum, Sudan, that provides free care. Hassab had just had surgery for rheumatic heart disease. “This 13-year-old boy could not have survived even a few years, but now I think he is hopeful that he will survive into adulthood and beyond,” Tedros said. As he described how Hassab had smiled at him, his voice faltered and he stopped for a few moments. “So for me,” he said, wiping away tears, “for me Hassab al Karim is SDG-3.”

It wasn’t the first time Tedros had cried in public, and some observers scoff at his displays of emotion. To others, this is his strength: that even as head of an international bureaucracy touching billions of lives, he is keenly aware of individuals. He talks easily to medical students, health care workers in the field, and patients. He frequently mentions his brother, who died young, Tedros believes of measles. That loss taught him to see individuals when he reads another staggering death statistic, he says.

“Empathy is very important for Tedros. He is a very emotional man,” Kickbusch says. It’s too early to judge whether his tenure will end up a success, but one thing is certain, she says: “He is in it with his heart and his soul.”

*Update, 11 February, 5:50 p.m.: This story has been updated to include the World Health Organization's new name for the disease.