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"Neglected tropical diseases drive me really crazy," Chan says.

"Neglected tropical diseases drive me really crazy," Chan says.

© Juan Manuel Herrera/OAS

In wake of Ebola epidemic, Margaret Chan wants countries to put their money where their mouth is

BERLIN—As director-general of the World Health Organization (WHO), Margaret Chan is often ranked among the most powerful women in the world. But her agency appeared to be powerless to stop a devastating epidemic of Ebola last year. Critics have slammed WHO's performance, and reviews have called for drastic reforms.

Chan is used to crises; as Hong Kong, China's Director of Health, she fought devastating outbreaks of bird flu and SARS before taking WHO's top job in 2006. Science spoke to Chan on 10 October here, where she talked about the lessons from Ebola and the dangers of antimicrobial resistance at a meeting of the G7 health ministers. Questions and answers have been edited for brevity and clarity.

Q: Last week marked the first time since March 2014 that not a single new Ebola case was reported. You must be relieved.

A: I think the whole world is relieved. Everybody is anxious to make sure that we get to zero cases and maintain zero. So we must keep up our efforts. We need two times the incubation period without new cases before we can declare this epidemic over. That means we have to wait for a minimum of 42 days.

Q: Even then the virus can come back, of course. The virus can persist longer than 42 days in the semen of male survivors, which seems to have caused a resurgence in Liberia. A Scottish nurse, Pauline Cafferkey, was recently taken back to a hospital 9 months after she recovered from Ebola. At what point can we really say this is over?

A: After the previous 22 Ebola outbreaks we did not have enough survivors to help us understand the disease, its transmission, its complications, and consequences. This is the largest outbreak. We have a lot of survivors. So WHO is working with partners, including the [Centers for Disease Control and Prevention] and the countries themselves to find answers to many of the gaps in science.

We have seen a case where the virus persisted in the U.S., now there is this case in the U.K. We need to see exactly what kind of symptoms she has. Of course we keep an eye on this development and are working closely with the U.K. government to get information. But also: We know Ebola exists in bats, and their geographic range covers 20 countries or more in Sub-Saharan Africa. So we should not be too surprised if we see another Ebola outbreak. But we are on the verge of having an effective vaccine; we have good, quick diagnostics, and we have some treatments. So, hopefully we now have the weapons we need to go to war with the virus.

Q: In retrospect, it seemed obvious that this outbreak would become huge. A deadly virus in a part of the world that had no experience with it, health systems neglected during years of civil war, and a population that was highly mobile across borders, distrustful of governments, and more inclined to seek out traditional healers. Why did WHO miss the significance of all of this?

A: With the benefit of hindsight, the mistrust is a major problem. If you look at the epidemic curve, by May 2014, the number of cases really seemed to be coming down. And all our partners were packing up, ready to go home. But instead of sending patients to a treatment center as early as possible, people in the community kept their loved ones at home and nursed them. It was like a peat fire spreading underground.

Q: But at some point, Doctors Without Borders (MSF) was very clear that the outbreak was huge and out of control. Still, it took WHO until 8 August to declare a Public Health Emergency of International Concern.

A: Information was not flowing up. That is a big problem. You cannot manage what you don't see and what you don't know. I think all of us underestimated the context of these countries. An old disease in a new context gave us surprises.

Q: WHO's Emergency Committee regarding Ebola recently criticized 34 countries for imposing "disproportionate" restrictions on travel to and from the Ebola region; it said this is hampering the response and recovery efforts.

A: This is a big problem. Countries that are affected by an outbreak should be transparent and report their diseases. Countries that are not directly affected should not impose trade or travel measures over and above what is recommended by WHO. This is part of the International Health Regulations [IHR], an international treaty with the good intention of building a collective defense system against a common threat. But the implementation of the IHR is very poor; there is a lot of disincentive. Why should I report? The minute I report, you impose a trade ban and travel ban on me. That is why we need to review the IHR and change them to provide incentive instead of disincentive.

Q: What could incentives look like?

A: We can encourage countries by telling them: “We will help you out but not just to contain the outbreak.” After the outbreak is done, we will do a gap analysis, together with the government, and bring in supporters, donors, to help them build a health system that is better capable of detecting an outbreak.

Q: And how do you punish countries for wrongly imposing travel restrictions?

A: We need to name these countries and put it on the web.

Q: It seems like WHO isn’t learning from the past. The Report of the Ebola Interim Assessment Panel, led by Barbara Stocking, noted that a similar review done after the 2009 influenza pandemic also made recommendations to reform the IHR; if those had been implemented, “the global community would have been in a far better position to face the Ebola crisis,” the review said. Why weren’t those ideas implemented?

A: I was director-general at that time. When I presented the recommendations to the governing body, they said: "Good. We thank you very much for that. But we don't have the resources to do this.” Because the report came right after the global financial crisis. That is why the Stocking report made another recommendation: Health cannot be left in the hands of ministries of health alone. It has to escalate so that heads of state, heads of government, will consider the social, financial, and human costs of nonaction.

Q: The Stocking report also recommended increasing WHO’s budget. At the World Health Assembly in May, you asked member states to increase their contributions by 5%; they rejected that. Are they keeping WHO from fulfilling its purpose?

A: I ask the same question.

Q: You're the director-general. You should give the answer.

A: I’m the equivalent of the CEO of a company. So member states are like the board members. I said to them: “If you want WHO to be strong and fit for purpose, keep your promises. Put your money where your mouth is.” But many governments support a zero nominal-growth policy for their contributions. Maintaining that policy for 10 years has reduced the purchasing power of my budget by about one-third.

Q: Money is one problem, but people have suggested other changes. One proposed reform is restricting the director-general to just one 7-year term in office instead of two 5-year terms. Without the need to be re-elected, a director might find it easier to criticize member countries. Is that a good idea?

A: I have told member states that it's an idea they should consider. This job is getting more and more political and more and more intense. Can you imagine 10 years in this kind of position, where you have 194 bosses? And they do not necessarily agree on the difficult issues. I don't want to sound ungrateful. I feel privileged to be given the chance of serving the organization. But many countries behave like a visitor to WHO, not a shareholder. With the exception of a few countries, like Germany, the U.S., and the U.K., they are not serious in managing the organization. But the Ebola crisis has given me another opportunity to fast-track reforms. No more discussion. I keep telling people: I only have 21 months.

Q: You have also advocated the idea of “white helmets,” teams of health workers ready to be deployed in a crisis. What exactly are your plans?

A: WHO is good in mobilizing support. But if that support is not prepared in advance, you cannot mobilize. Every country must have a rapid response team: epidemiologists, public health, clinicians, information specialists. When they are trained together, when they exercise together, when they mobilize as a team, they can hit the ground running. The idea is to have a core capacity at WHO. If the outbreak is small, we manage on our own. But if it is beyond our capacity, I mobilize all these pretrained teams, from the countries, or [the United Nations Children’s Fund], the World Food Programme. WHO should be the conductor of an orchestra.

Q: The most positive comments in the Stocking report were about WHO's role in coordinating research and development. Thanks to a WHO-led trial in Guinea, we now have the first proof that one Ebola vaccine actually works. The report said WHO “will need to be involved in research and development work for future emergencies.” What form will that take?

A: With Ebola, we brought people together and we said: “Okay, this is the situation. What are the molecules that are being developed, what is their potential?” Now, we want to turn things around. This is an opportunity to change the culture of people. Let's bring people together in advance, to develop a blueprint for R&D for future high-impact pathogens. Everybody has to agree what is a reasonable clinical trial design. We bring the regulators in right at the beginning and ask them: “What kind of information do you need?” And then the WHO will give the target product profile. Hey, don't give me a product that requires minus 80°C, that is not easy to do. I promised the member states I will present this blueprint for their consideration in 2016.

Q: MSF has played a huge role in fighting the Ebola outbreak. MSF President Joanna Liu recently said she is very concerned that public health crises were increasingly being addressed by the private sector instead of governments.
I agree with her. The duty to the well-being and the health of people is the primary responsibility of government. It is enshrined in the WHO constitution. And this is the problem: Leaders do not keep their promises to their people. If the world continues like this, we are not moving into a good space. We need to remind leaders that gaining trust is the only way to get re-elected. But, unfortunately, too many countries do not have that kind of system.

Q: World leaders just agreed on a set of new, very ambitious goals at the United Nations: the sustainable development goals, or SDGs.

A: I am very excited about the SDGs. One of the ministers at the G7 meeting said: “Dr. Chan, what you are telling us [about how badly the IHR are implemented] is very worrying. We just came away from New York endorsing 17 goals, 169 targets. If we, the political leaders, do not implement them ...”

Q: He was worried what would happen if the world misses those goals?
A: Yes. And I said: “You better not do that. The community will not trust government anymore.”

Q: But that happened with the Millennium Development Goals, didn’t it? There were only eight of them but we didn't achieve them.
It is still better than not having the millennium goals. The health-related goals surely have made progress. We must build on that achievement. I believe quiet diplomacy and encouragement work. It's just like having a kid. You cannot hammer children all the time. You need to encourage them. Give them some freedom. That is how I manage my boy.

Q: You manage your bosses like you manage your boy?

A: Actually, my bosses are not behaving as well as my boy. [Laughs] Every year before school starts, I have a conversation with my son. What is your target this year? And I will say: “Mommy also has a target. Son, every year I want you to be in the top 25% of your class.” And he will say: “Mom, your target is easy.” So I say “Okay, then you can ride your bicycle, you can watch TV, you can play your game.” I don't want to micromanage. What makes me unhappy is that my bosses, they promise and talk, but then they don't walk the walk. That is the problem.

Q: In recent years, organizations like the Bill & Melinda Gates Foundation, the Wellcome Trust, the Global Fund, and others have taken on ever bigger roles in global health. Is WHO becoming irrelevant amid these new giants?

A: This is a question for member states. These initiatives are good, because they bring attention, energy, and resources. But they do not have the underpinning, the system to deliver. If you look at the three countries affected by Ebola, they are 10 years postwar and there has been no lack of support. Donors are asking: “We have been investing in these countries for 10 years; how come they cannot withstand the shock coming from an outbreak? How come they do not have the system to detect an outbreak early?” Because the way development assistance was done was wrong.

Q: In what way?

A: At the G7 meeting, Dr. Bernice Dahn, [the Liberian minister of health], said when governments pay international [nongovernmental organizations] to go and do the delivery of service, the people in the community trust these organizations that take care of them instead of the government. At the same time that you are building government institutions, making the government stronger and holding it to account, you are undermining it. Coming from her, that was really very convincing.

Q: The counterargument is that if you give the money to governments, it may disappear.

A: I fully agree with you. It’s another conversation I had with member states: When you get support from development partners, why do you put the money in Switzerland, in private accounts? Instead of putting it to work? A director-general must have the courage to speak truth to power. It's unpleasant but you have to tell them.

Q: At the G7 meeting of health ministers, you talked not only about Ebola but also about antimicrobial resistance. What did you tell them?

A: Governments need to pay attention. We are seeing more and more drug-resistant disease and the drug pipeline is empty. The last group of antibiotics we have was developed almost 30 years ago. If we run out of antibiotics we are going into an era where simple infections can kill people again. We don't want that. The health sector alone cannot do it. The use of antibiotics is huge for cattle, pigs, poultry, and even for fish, farming, and plants. We agree that antibiotics should treat sick people and sick animals. But why are we using antibiotics as a growth promoter?

Q: What should be done in concrete terms?

A: Doctors should not prescribe antibiotics if they are not needed. Animal sector: Don't use them if they are not needed. ... Invest in R&D, because the pipeline is empty. When new antibiotics become available, we may need to impose very tight and stringent regulatory measures to ensure that they are used only on prescription[s]. Anywhere you go, you can buy antibiotics over the counter. That is not a good practice.

Q: You will step down in 2017. What do you hope to achieve until then? What do you hope your legacy will be?

A: Since I took office in 2006 I have been promoting very important programs. I have made women’s health the top priority in my first term and my second term, and I have been working with [U.N.] secretary-general Ban Ki-moon and other people to promote the global strategy for women and girls. That will continue. Neglected tropical diseases drive me really crazy. This group of diseases, including malaria and dengue, anchors 1.5 billion people in poverty. How can you expect them to get a job when they cannot even go out of their small home? When I saw photographs of elephantiasis, it really just blew my mind.

Every year 150 million people cannot afford health care costs, and 100 million out of the 150 million are pushed into the poverty trap. In order to prevent that you must have a safety net. That is why I promote health system strengthening and universal health coverage.