In May, the World Health Organisation will appoint its new Director General who will continue the organisation’s commendable work to ensure the highest attainable level of health for all people. In the coming weeks, we will publish interviews with the candidates for Director General. This week, we were fortunate to speak to Dr. David Nabarro, the UK’s candidate, who spoke eloquently about his desire to work with African countries on retaining talented health professionals, and the positive health outlook for the continent.
1) Why do you want to be Director General of the World Health Organisation, and how does Africa feature in your world view?
The WHO is a specialised United Nations organisation that sets the standards, which enable nations to promote better health in the face of diseases that have the potential to cross borders and cause outbreaks. I’ve always believed that the WHO is a vital organisation as part of global development. I believe that the WHO is essential, as it can set standards for all aspects of health to which every country can aspire and seek to move towards as part of their development work.
Standard setting and managing big outbreaks are the two focal points for the WHO, and they are also the areas that I’ve focused on my whole professional life. In the past 45 years, I’ve developed extensive experience addressing diseases and outbreaks for which standards are necessary, as well as primary care.
I believe that Africa is both a continent with immense promise, as well as a highly important region for the WHO. First of all, the continent boasts many nations that have experienced strong economic growth. It also has enormous potential for sustainable energy and agricultural development. In addition, Africa has masses of capacity for innovation, which we can see in many of its countries. What’s more, it has a dynamic and increasingly connected young population who are harnessing technology for real impact.
I also believe that Africa has the potential to ‘leapfrog’ the so-called advanced nations in all aspects of development. This is particularly true in health where the combination of high levels of connectivity and huge numbers of young people who could serve as community health workers may have real impact. I think that the WHO and Africa’s potential could coalesce and lead to some very exciting developments. We also need to ensure that the WHO can help African communities deal with some of the communicable diseases that are affecting lower income citizens’ quality of life. I’m referring to malaria, in particular, but also the so called neglected tropical diseases such as Trachoma, Lymphatic filariasis, and Onchocerciasis.
2) According to the WHO, the continent “bears the brunt of more than 24% of the global disease burden, but has access to only 1% of health workers”. What can Africa do to train and retain high-quality health professionals?
I’d like to split this question into three parts and address each aspect separately. First of all, let’s look at the question of high-quality professionals. For me, this means professionals who can deal with all the activities that are needed to produce health and sustain healthiness. We need to look at the totality of professional mix that is needed, and not just focus on one group. African countries need to nurture community health workers, clinical workers and nurse midwives. They also need to recruit talented people who can serve as pharmacists who obviously provide an essential service, as well as technicians who work in x-rays or radiology or laboratory personnel. The WHO can play a vital role in assisting African countries to increase the capability and self-respect of all health professionals.
Second, there is the question of training. As far as possible and wherever feasible, training is best done at the local level. In the early stages of my career, I worked as a field worker in Asia where much of my time was spent training community health workers. I travelled to their places of work and trained them in location in many ways. I want to stress the absolute need for good-quality, local training that will prepare African health professionals to make the greatest possible impact in the context that they will be working in. We do need to make sure that the WHO sets standards across nations, and that people have the best quality information on this.
Finally, let’s consider retention. It’s crucial that esteem for trained professionals, as well as their broader self-respect, is encouraged and maintained at all times. Otherwise, health professionals will look for opportunities to take their skills elsewhere, whether it be moving from countryside to town, transitioning into the private sector, or leaving their countries. I believe that this is a huge issue, and I would be keen to work with African countries on retention challenges.
3) In December the World Health Organisation’s Africa office announced a steep rise in risk factors for non- communicable diseases. What steps can African countries take to combat these diseases?
For much of my professional life, I’ve been working with African countries on the totality of the health challenges they face. I have watched and been densely engaged as the levels of non-communicable diseases have become higher. While I was at DFID, I worked with the Government of Tanzania on a study of non-communicable diseases in the country. Our research revealed that more than 5% of the country’s population was diabetic. This was in the mid 1990s where the impact of non-communicable diseases was not widely understood.
Twelve years on, it is widely known that diabetes, hypertension and cardiovascular disease, cancers, and respiratory infections are all serious causes of sickness and death throughout the world, but especially in Africa. This is particularly true of a country like Zambia where my work demonstrated that there is a double burden of nutritional disease.
Prevention is the only way to deal with non-communicable diseases effectively. There is no scope to tackle NCDs through a curative programme, except obviously to help those who are already sick. This is because the programming takes place in early childhood and adolescence. Given that seven out of 10 deaths globally are due to NCDs and the number in Africa is very much on the rise, the prevention task is enormous. African countries need well-crafted prevention strategies that engage all relevant government ministries, are monitored by the whole of government, and receive leadership from the president or prime minister. These strategies also need to engage the broader civil society as well as business. At times, it’s said that several non-communicable disease challenges result from business activity, and my answer is, ‘Engage with them and try to prevent NCDs’. It’s crucial that preventive approaches involve all members of society.
We also need to start from a very young age, and this means engaging parents as well as children. We must recognise the perils of obesity, particularly young childhood obesity, and address dietary problems such as inappropriate levels of salt or sodium very early on. What’s more, African countries need to ensure that sedentary lifestyles are discouraged, wherever possible, and that there is plenty of scope for regular exercise including in schools. The Ministry of Education in individual countries plays a hugely important role in preventing non-communicable diseases.
4) How can African countries ensure their wider preparedness for health emergencies?
Preparedness to deal with health emergencies or indeed any problem is about being alert, being ready and being tested. Let’s start with being alert. African countries are really only able to detect emergencies if they are alert to potential dangers. When something strange starts happening, health professionals need to register it and then be ready to act. This requires quite a lot of confidence. People who have worked in clinical medicine know that at the beginning, you never really know what’s a serious sign in a patient and what’s not serious. It requires a lot of time, experience and support from good teachers for health professionals to develop the capacity to distinguish concerning health problems from what’s normal. What’s more, it’s very important that supervisors respond positively to an alert signal even if it transpires that the alert signal is perhaps unnecessary. When receiving a report on cases of a surprising disease, if a supervisor responds negatively, then the next time the alerter will not send the alert. Hence, high levels of emotional intelligence are needed to get alert systems working properly. I think that working with people to help them sound the alarm well and do good alert work is a crucial part of the skills needed to deal with emergencies. An emergency does not become an emergency if professionals deal with it quickly and have the proper protocols in place.
Health professionals need to have the necessary response capacity and to be ready so that they can take appropriate action once they receive an alert. This includes helpful protocols, appropriate stockpiles of medicine and other diagnostic equipment
Finally, being tested is the most important part of preparedness for health emergencies. Countries will only know if they are good at registering alerts or ready to respond if they have tested themselves. People who work in emergency services do drills because otherwise they can’t properly assess preparedness. This also means doing drills without warning. I’ve been working in emergencies since 2003, and I have argued for greater importance to be given to testing in various settings. I strongly believe that health professionals will not know whether they’re prepared to deal with emergencies unless they’ve tested their preparedness. I know that people find testing inconvenient, but it’s absolutely crucial.
5) The Sustainable Development Goals recognise the private sector as a key driver of development. How can for-profit businesses work with African countries and the WHO to achieve the SDGs’ ambitious agenda for health?
From my understanding, the Sustainable Development Goals view the private sector as a crucial partner in development, but I’m wary of saying that it’s a driver. I think that there are multiple drivers in this partnership, but people themselves are right at the centre. At the end, sustainable development requires all people to work together for equitable outcomes. We can make this collaboration possible by creating spaces where different groups of actors can come together. It’s vital that representatives of the people, whether local government leaders or parliamentarians, are at the centre of these discussions. That way, we can ensure that the agenda is set by the people and the accountability is to the people. We can also ensure that the 169 targets in the SDGs are well understood and used as a framework for assessing developmental progress.
The Sustainable Development Goals are a very exacting framework within which businesses should be welcomed conditionally. There’s no point in welcoming a business whose activities are going to undermine the realisation of the SDGs. For example, if a business arrives in a community and cuts off people’s access to water, this activity needs to be resisted. Going forward, we will only be able to achieve the partnership that is necessary for development and engage productively with businesses if all actors are accountable to each other.
6) If you were elected Director General of the World Health Organisation, what do you think global health will look like by the end of your term?
Global health is changing at an enormous rate. Increasingly, people recognise that health outcomes are socially determined, and this is reflected in the Sustainable Development Goals. Good health involves lifestyle issues and access to goods such as water and sanitation, nutritious foods, and shelter. I would like to see the relationship between health and the Sustainable Development Goals instilled in the WHO’s culture and actions at all levels. Health is a clear outcome and contributor to all the SDGs and is embedded across the whole framework.
Second, the WHO also has specific functions that include dealing with health crises, which need to be predictable, dependable and competent. If I were elected Director General, I want to ensure these functions are clear to all stakeholders by the time I finished my term of office.
Third, I want to ensure that we truly value all health workers, whether they are community wealth workers, professionals who work in clinics and hospitals, or specialists. These are really vital people in society. The mother is often the starting person, as she is the main health giver for very young children. Respect for health givers is at the heart of all good health action, and I would like to see it restored.
Last, I would like the WHO to be seen as the organisation that catalyses action by others, partners with others, and is judged on the impact that it has through others. This notion of a catalytic partnering impact organisation is perhaps the most important new attribute that I would hope to see in the WHO after my term.
7) Following on from the last question, if you were appointed Director General of the World Health Organisation, what do you think the health outlook for sub-Saharan Africa will be by the end of your term?
I think that the health outlook for sub-Saharan Africa is good. Sub-Saharan Africa has immense potential and many brilliant people at all levels. From 2014-2015, I was working with West African countries to address the Ebola crisis, and I want to emphasise that African citizens really halted the epidemic. Outsiders were helpful, but African people did the real work. Since 2000, malaria mortality rates have declined by almost 50%. Again, this can be attributed to the work of the people. If I were elected Director General of the WHO, I would enhance the incredible work that is already being done in health on the continent, and empower action because that’s where my heart is.
If I become Director General of the WHO, I would also hope to share some of Africa’s greatest successes with the rest of the world. I believe that African countries have much to teach their counterparts across the globe.
For further information on Dr. Nabarro’s candidacy, please read his Reflections