Who's using whom?

Will China gain influence from having one of its people at the head of WHO or will the winner be WHO itself as China becomes more engaged in fighting infectious disease? Anne Glusker reports

British Medical Journal | November 18, 2006

Dr Margaret Chan of China was elected last week to be the new director general of the World Health Organization. Chan, 59, a former public health minister of Hong Kong and, most recently, chief technical and administrative officer at WHO, won after rounds of secret balloting at the organisation's headquarters reduced the original field of 13 candidates to a shortlist of five and then to one opponent, Julio Frenk of Mexico. Chan won convincingly, with two thirds of the vote, the culmination of a campaign season marked by allegations of influence peddling.

Two main and interrelated questions shadowed Chan's campaign and will be the backdrop against which critics will watch her tenure unfold. One concerns her handling of the severe acute respiratory syndrome (SARS) and avian flu epidemics while she was Hong Kong public health minister; the other question involves her relationship with China. Although some people believe that having Chan at the head of WHO will more fully integrate China into the world health community, making it more cooperative in future disease outbreaks; others scorn that notion, saying that China is using WHO strategically to raise its standing in world opinion.

Several actions by China during the SARS and avian flu crises raise questions about its behaviour and attendant questions about whether Chan has the wherewithal to stand up to the Chinese government, which supported her campaign. Jiang Yanyong of the People's Liberation Army General Hospital in 2003 exposed under-reporting of SARS and was then held under house arrest (BMJ 2004;329:130). In addition, China was not forthcoming in offering samples or information to WHO and others during avian flu outbreaks.

Kwok Ka-Ki, medical sector functional constituency representative of the Legislative Council of Hong Kong, said: “Her [Chan's] performance in the 1997 bird flu outbreak and the 2003 SARS outbreak was not impressive to the people of Hong Kong. She has played down the importance of both outbreaks. She was not particularly keen to alert the public and not particularly keen to dig out the facts.”

But, looking toward the future, Kwok added: “I hope her appointment will make China engage itself in the war against infectious disease. China is a likely source of infectious disease and an engaged China will be beneficial to the rest of the world.”

Chan is the first Chinese person to head a large United Nations agency and the first Asian woman to head WHO. She is seen as a savvy political operator who managed to evade strong criticisms over lack of transparency while she was public health minister and then go on to a successful tenure at WHO as chief of communicable diseases.

Although some people doubt her ability to face down China, which strongly supported her campaign, she receives high marks as a capable and effective manager from those who have worked with her in Geneva headquarters. Because she got her medical degree from the University of Western Ontario in Canada, she has experience of Western attitudes. She emphasises this by saying, “I no longer carry my nationality on my sleeves. I leave it behind.” Whether she will be able to put this into practice remains to be seen.

Chan will have to face many internal controversies at WHO—for example, whether the organisation should focus on setting policy or continue its in-country operational work; how WHO works with other UN agencies to avoid duplication and how it partners with newer, powerful players on the world public health scene, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Gates Foundation; whether its emphasis should be on communicable disease or perhaps on chronic illnesses that get less attention, such as diabetes and heart disease.

In her acceptance speech, Chan spoke with surprising directness on some of these issues, saying that “WHO is not the implementing agency within countries, but can support country priority setting.” She also said that the organisation “must not spread our resources too thin…We must know our comparative advantage and stick with activities that WHO is uniquely well suited to perform.” She did not, however, specify what those activities are.

She delineated two areas of especial concern to her: Africa and women. The section of her speech on women seemed to stem from genuine conviction. This is logical given that her early work was in maternal and child health. She made the point that when she spoke about women, she was not talking about maternal health alone. “Women do much more than have babies,” she said, adding, “Unfortunately their activities in households and communities, coupled with their low status, make them especially vulnerable to health problems—from indoor air pollution and multiple infectious diseases to violence.”

In November, just before the WHO election, China hosted a trade conference for 48 African states in Beijing that resulted in $1.9bn (£1bn, €1.4bn) in trade agreements. In the portion of her speech where Chan stated that “the people of Africa carry an enormous and disproportionate burden of ill health and premature death,” some might hear echoes of this recent wooing of Africa.

But Jerry Norris, director of the Center for Science in Public Policy at the Hudson Institute in Washington, DC, thinks that interesting developments may come from the burgeoning alliance between Africa and China: “Donors have had an amazingly patronising attitude, while China is more respectful. After 40 years of the same colonial paradigm, China takes a different perspective—it's a real partnership.”

Chan's next move will be to select a deputy, a point the WHO Executive Board insisted on, after the sudden death last May of her predecessor, Lee Jong-wook of South Korea. In the past, some WHO directors general chose to have deputies, but others, fearing competition, did not.

Dr Lee had selected a deputy by writing the name of his chosen successor in a sealed letter. He discussed it with very few people at WHO. When Dr Lee died there was debate over the process and the validity of the letter. Hoping to avoid a repeat of this situation, the board stipulated that Chan must choose a deputy. Certainly, issues of geopolitical balance and the recompense of favours will play a role in this selection. Until Chan takes office in January, the current deputy, Anders Nordström of Sweden, will stay at the helm of the organisation. Chan will serve until June 2012.

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