Who should direct WHO?

ast week, member states of the World Health Organization (WHO) advanced another step in the nearly 1-year rigorous process of selecting its next director-general. Candidates for the position presented their vision of international health work and the role of this global health body. Having worked at WHO in a number of capacities in the area of infectious diseases, I know well that international health covers a wide breadth of issues. Add to that noncommunicable diseases and matters such as intellectual property and universal health coverage, and it becomes clear that the next director-general must be a jack of all trades, but also a master of one— leadership in public health. Leadership in this role is about conceiving and articulating a vision, staying faithful to that vision in the face of undue influence, and effectively engaging with not only governments, but with all stakeholders to gain their support and enable the vision to be realized. International health not only concerns the transborder spread of infectious diseases and epidemics, which have recently been high on the political and media agenda. It is much broader and includes many health challenges, ranging from antimicrobial resistance and hazards such as natural disasters, to war, nuclear accidents, and chemical spills. Noncommunicable disease risk factors such as poor nutrition, lack of physical exercise, and smoking also cross international borders—physically, as with the spread of chemical spills or nuclear fallout, and through advertising and marketing. They are therefore an important part of international health, although they attract less media interest. These factors are often driven by sectors outside of health, unlike infectious diseases, which are mostly naturally occurring and depend on government reporting and action. This complicates the landscape of those who must come to the table when problems are discussed. In addition, public health decision-making by WHO must be safeguarded from undue influence. Thus, there are constraints on the director-general’s interaction with nonstate actors. For example, on a day-to-day basis, the director-general must discuss international health problems with nongovernmental organizations and private companies that deal with pharmaceuticals, food, alcohol, and other goods. This adds even more complexity to the director-general’s job, as the decisions made must be the right ones for public health. WHO’s focus on improving preparedness for public health emergencies, especially for infectious diseases with epidemic potential, must also be maintained. For example, its Research and Development Blueprint was initiated last year toward the end of the West Africa Ebola crisis. This year, proposals on technologies emerged, ranging from vaccines and immunotherapy to diagnostics. The next director-general must not only continue to encourage innovative thinking in preparedness, but must also draw the public and private sectors together to develop these global public goods and ensure equitable access for all who need them. And finally, the WHO regional structure must be supported through constant interaction with the director-general. Each regional office has a director who is nominated by the WHO member states of the region— the same states that collectively decide on who will be director-general at the global level. It has often been said by senior staff at WHO that much more effort must be made to ensure that country, regional, and headquarters staffs work in harmony, compared to the effort spent on technical activities that support country needs. On 1 July 2017, a new WHO director-general will take office. In the final decision-making steps, it will be important to identify the candidate who will be a technically sound leader with a deep understanding of politics and an ability to channel all stakeholders to the right outcome. This job takes boldness in vision, and the skills to bring others along with that vision. —David L. Heymann Who should direct WHO?