Tedros Remarks Racism Underpins Responses to Global Conflicts

“Maybe the reason is the colour of the skin of the people in Tigray.” Dr Tedros confronted world leaders last week for their neglect of “the worst disaster on earth”—a storm of conflict in Ethiopia, extreme weather across the Horn of Africa, and soaring food, fuel, and fertiliser prices exacerbated by Russia’s invasion of Ukraine.

Tedros is not politically neutral, given his Tigrayan background and former high-level roles in the Ethiopian Government. But his suggestion that racism underpins the world’s apparent indifference is worthy of consideration, by both the political and health communities.

A humanitarian catastrophe is clearly taking place in the Horn of Africa. Many millions of people are suffering. Ethiopia, for example, saw substantial declines in communicable, maternal, neonatal, and nutritional diseases and disability between 2000 and 2019. Life expectancy rose from 46·9 years to 68·8 years, a testament to the power of strengthening community-based health programmes. However, the Tigray civil war, which has spilled over into most of northern Ethiopia, is rapidly undermining these gains. The UN now estimates that at least 25 million Ethiopians need humanitarian assistance and protection, 42% of whom are children. In Tigray, 80% of health facilities have been looted or damaged, and medical supplies are in short supply. Half of pregnant or lactating women and one in three children under 5 years is malnourished. Women and girls are being forced into sex work to survive. Access to maternal health care has been compromised. As a World Report this week describes, Tigray was on the verge of eliminating obstetric fistula, but cases are now soaring because of the conflict.

His comments came the day after he began his second term as WHO Director-General. Tedros’ re-election was uncontested, but his first term was by no means uncontroversial. He faced unprecedented challenges in the COVID-19 pandemic, and there were several successes: WHO strongly voiced the pandemic’s threat to low-income countries and campaigned vigorously for equity; more than 1.4 billion vaccine doses have been delivered via COVAX. Campaigns to counter misinformation and disinformation were rapid and clear. Progress was made in decreasing tobacco use and eliminating mother-to-child transmission of HIV and syphilis.

Tedros’ signature issue, however, was his ambitious Triple Billion programme: the promise that by 2023, one billion more people would be enjoying better health and wellbeing, one billion more people would be benefiting from universal health coverage, and one billion people would be better protected from health emergencies. There has been progress, but projections suggest serious shortfalls in securing universal health coverage, with only 270 million more people expected to be benefiting by 2023. In reorganising WHO programme clusters towards Triple Billion targets, crucial work around women and children’s health and non-communicable diseases was weakened. This was a mistake.

A grim stain on WHO’s reputation was left by the revelation that staff involved in the Ebola virus outbreak response in DR Congo had sexually exploited and abused local people. WHO’s functioning, if not its very purpose, is under increasing scrutiny from politicians, who are hostile towards international institutions.

These are challenges of governance as much as technical ability. Power has been increasingly centralised around the Director-General’s office under Tedros’ leadership. This strategy might be advantageous in a crisis that demands a commander-in-control. But a lack of depth in wider leadership leaves shortcomings in the organisation. WHO needs people of high calibre in programmatic leadership positions. A wealth of expertise is available in WHO regional offices, and they deserve more support, engagement, and visibility. Member states might in fact prefer to fund regional offices rather than the Geneva headquarters. Former Director-Generals appointed strong personalities, leaders in their areas of expertise and who had real convening power. Ala Alwan, for example, while Assistant Director-General for WHO, led the development of a global strategy for the prevention and control of non-communicable diseases that was endorsed by the World Health Assembly in 2000. In its wider leadership, the WHO of today suffers a knowledge and expertise vacuum, with a heavy reliance on external experts and management consultants. Tedros would be wise to think about how leadership and responsibility is devolved to other dimensions and domains of his team.

No doubt, there will be many health emergencies across the world in the next 5 years. But Tedros should start his second term by tackling weaknesses at home.