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There were 186 member states eligible to cast ballots. Eight others had not paid their dues in time or were not represented at the 10-day gathering. In the final round of voting, there were two abstentions, observers said.

Tedros told the delegates that it was “pure luck” that he was competing to lead the WHO, noting that when he was growing up in Ethiopia, he was seven years old when his younger brother was killed by a common childhood disease and that it could easily have been him. “While WHO has never had a director from Africa, no one should elect me because I am from Africa,” he said. Observers tweeted that Ethiopian delegates could be seen hugging and high-fiving one another after their countryman made it to the second round, which Tedros went on to win with 121 votes versus Nabarro's 62.

The election comes at a critical time for the WHO. It has experienced huge budget cuts over the years, lost many talented staff members and was heavily criticized for its slow and ineffective response to the 2014 Ebola epidemic in three West African countries that killed more than 11,000 people. A recent editorial in the Lancet said the election comes at a time of “unparalleled uncertainty” for the organization. It said: “Vastly more is expected of WHO while its role is contested and constrained.”

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All three candidates had pledged deep changes to the U.N. agency, promising greater accountability and transparency. The winner, who will serve a five-year term, takes office July 1, succeeding Margaret Chan, who has held the post since November 2006.

The United States, its largest donor, was represented by Health and Human Services Secretary Tom Price. He congratulated Tedros and called on the WHO to reform and strengthen the organization and “enhance the ability of all nations to protect the health of their people.” Even as he noted that “global health security begins at home,” the Trump administration's budget for 2018 calls for massive cuts in spending on U.S. scientific research, global health, disease prevention programs and health insurance for children of the working poor.

As the cash-strapped WHO seeks more money to fund responses to worldwide crises, it has also been struggling to control its travel costs. The WHO, with a $2 billion annual budget, routinely spends about $200 million a year on travel, far more than what it spends to fight some of its biggest problems in public health, according to the Associated Press. The WHO said nearly 60 percent of the cost is for travel of external experts to support countries and for representatives of member states to travel to technical meetings and sessions of WHO governing bodies.

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Only the WHO can declare a global public health emergency. But dealing with epidemics is only part of its responsibilities. It has considerable influence in setting medical priorities that affect billions of people. Its mission includes tackling antimicrobial resistance, confronting the growing problems of obesity and diabetes, and reducing maternal and infant mortality during childbirth.

Public health experts say one of the biggest challenges facing the WHO is getting rid of the deeply entrenched politics that affects the selection, promotion and support of its staff. One primary reason that the WHO’s initial response to the Ebola outbreak was “not competent” is that “they didn’t have the right people in the right places,” said Tom Frieden, former director of the Centers for Disease Control and Prevention. Highly competent representatives were later appointed in the three West African countries. With good representatives, the “WHO can accomplish amazing things,” he said in an interview before the election.

But senior positions, such as the WHO assistant director-generals, are appointed on a “geographic quota system,” Frieden said. “Many have little technical expertise in the area they are overseeing. Whoever becomes the next will only succeed if they make their key human resource decisions on the basis of technical and operational excellence.”

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Several global health organizations welcomed his selection.

Jeremy Farrar, who heads the Wellcome Trust, a London-based global biomedical research charity, which did not endorse a candidate, said Tedros “will bring great insight and the political leadership necessary to restore trust in the WHO at a critical moment in its history.” He said the new WHO chief “has the power to herald a new era in how the world prepares for and responds to epidemics, including building partnerships, strengthening public health systems, and developing new vaccines and therapies that are available to all who need them.”

Steve Davis, the chief executive of PATH, a Seattle-based international health technology nonprofit, also said it will be important for Tedros to act on lessons learned from Ebola epidemic in West Africa and the current outbreak in the Democratic Republic of the Congo so the global community is better prepared to respond swiftly to future outbreaks before they spiral out of control. He also urged the new leader to increase global access to lifesaving medicines and technologies and continue progress toward ending HIV/AIDS, malaria, tuberculosis, polio, and preventable maternal and child deaths.

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In the run-up to the vote, the battle seemed to narrow to a race between Tedros and Nabarro, who has wide experience on the front lines of global health and in the U.N. system, where he has spent much of his career. Tedros, 52, was Ethiopia’s health minister from 2005 to 2012 and foreign minister until 2016. He was the only nonmedical doctor among the three candidates. He was backed by the African Union as well as countries in the Pacific and the Caribbean. He presided over a dramatic expansion of Ethiopia’s health system and reductions in infant and maternal mortality as well as deaths from malaria. He also extended the reach of the health system deep into remote rural areas.

But just before the election, he and the Ethiopian government were accused of covering up cholera outbreaks, referring to them instead as “acute watery diarrhea.” It is not clear whether Tedros had any input in the government’s decision, but the change occurred during his tenure as health minister. He has denied any coverup.

The accusation against Tedros prompted Frieden to point out last week that while “not optimal,” many countries report cholera to the WHO as acute watery diarrhea. After Tedros's election, Frieden praised him. “Tedros is an excellent choice to lead WHO,” he said in an email. “He succeeded in Ethiopia, making remarkable health progress by rapidly reforming a sclerotic bureaucracy and implementing effective community-based services,” Frieden wrote. “Precisely the same thing is needed to make WHO effective providing technical guidance and improving support to countries.”

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Tedros has also been criticized by human rights groups because of his ties to a government known for its poor human rights record.

Nabarro has had years of experience dealing with outbreaks and crises for the United Nations, including avian flu, the 2004 Indian Ocean tsunami, and Ebola. But critics say that as a longtime insider, he would have difficulty introducing the radical change needed to overhaul the agency.

Nishtar, the Pakistani doctor, had the least amount of management experience and experience with outbreaks. She served briefly as health minister and has worked on noncommunicable diseases for years as head of a nongovernmental organization. She is the only candidate who promised to serve a single five-year term.