Public Health Leaders in the World Health Organization

ACUNS 2015 Annual Meeting

Workshop Panel 12 13 June 2015

In my long career in WHO as a Personnel Officer, I have served under several

Directors-General: Dr M. Candau (1953-1973), Dr H. Mahler (1973-1988), and briefly under Dr H. Nakajima (1988-1998). My last post before retiring from WHO was as Assistant Chief of Personnel (now Human Resources).

While WHO’s governing bodies and the Director-General have the principal roles in approving the organization’s programmes and budgets, a number of individuals have played, openly or discreetly, an important role as advisers to the chief executive, or as significant leaders in specific programmes.

Among them:

Milton Siegel (USA) served WHO in 1947 until 1971 as Director of

Administration then Assistant Director-General for Finance and Administration. He is credited for having created and maintained WHO’s administrative policies and structure, gaining the reputation of the best-managed UN agency at the time. I knew him well, as Personnel was under his jurisdiction 1.

Dr Joshua Cohen (Israel) was a close and influential adviser to Dr Mahler from 1969 to 1973. He said that he was the initiator of the “Health for all by the Year

2000”concept. He resisted political pressures and battled against UNICEF’s Jim

Grant. He left WHO when Dr Mahler’s term ended 2

Dr D.A. Henderson (USA) led the Smallpox Eradication Programme to a successful ending in only ten years, 1966-1977.

1 Interview of Milton P. Siegel, in Archives of WHO, 1982 and 1986 http://www.int/archives/fonds_collections/special/oral_history Accessed 8 December 2014. 2 Archives of WHO, Association of Former WHO Staff (AFSM), Oral History Project, Transcript of an oral interview with Dr Joshua Cohen, Moderated by Dr Mirial Hirschfeld, 16 July 2006. 2

Dr J. Mann (USA) made the Global Programme on AIDS (GPA) from 1986 to

1990 the largest single programme in WHO.

My presentation focuses on Dr Henderson and Dr Mann.

Dr Donald A. Henderson

Dr Henderson, American physician and epidemiologist, was head of the World

Health Organization’s Smallpox Eradication Programme at its Geneva, Switzerland, headquarters from 1966 to 1977. He was born on 7 September 1928 in Lakewood,

Ohio, USA.

Henderson received his M.D. from the University of Rochester School of

Medicine in 1954. He earned an M.P.H. degree in 1960 from the Johns Hopkins

School of Hygiene and Public Health. Between his internship and residency, he worked in the Epidemic Intelligence Service of the US Communicable Disease

Center (now the National Centers for Disease Control and Prevention) in Atlanta,

Georgia (1955-1957 and 1960-1966).

Henderson joined WHO in 1966 as chief of the Organization’s Smallpox

Eradication Programme. In October 1977, the last case of smallpox was reported in

Somalia. In 1980, smallpox was declared eradicated by WHO, a major and lasting achievement for WHO.

The WHO smallpox eradication programme

Over the twentieth century, smallpox caused around 300 million deaths worldwide, mainly in low- and middle-income countries. It threatened 60 percent of the world’s population, killing every fourth victim, scarring or blinding most survivors, without known treatment 3 The initial response of member states to WHO’s proposed

3 Kelley Lee, The World Health Organization (WHO), Routledge Global Institutions (New York/Manchester) 2009, 54-58. 3 establishment of a Smallpox Eradication Programme in 1950, and between 1953 and

1955 was negative. It was only in 1958 that, following a successful national smallpox eradication programme in the USSR based on compulsory vaccination, that eradication was thought to be feasible.

In May 1966, the World Health Assembly approved the intensified global smallpox eradication programme (Res. WHA19.16).

According to Dr Henderson 4 , the Director-General, Dr M.G. Candau, was not happy with the WHA endorsement of the proposed smallpox eradication in the light of the malaria eradication not going well. He was concerned that the failure of a second eradication programme would reflect badly on WHO and the public health community. As the United States was eager to have the programme approved, he asked that an American be assigned to head it, so that if the programme failed, the responsibility would be shared with the US. The Assistant Surgeon General called

Henderson to Washington to tell him he was assigned to WHO in Geneva. Dr

Henderson himself was reluctant to accept the international job, as he had been in charge of a US smallpox eradication-measles control programme for only a year under the US Centers for Disease Control in Atlanta, Georgia. He accepted to come to Geneva for eighteen months and stayed for eleven years.

In the words of Henderson, the virus had qualities, which made it “a relatively easy disease to eradicate”. “The vaccine was effective, long-lasting, relatively cheap, easy to administer, easy to transport, it worked with only one dose and required no refrigeration”. Outbreaks were easily identified because every victim had a visible rash.

4 WHO Bulletin, “Smallpox: dispelling the myths. An interview with Donald Henderson” http://who.int/bulletin/volumes/86/12/08-041208/en Accessed 30 November 2014. 4

In the late 60s and early 70s, conventional wisdom held that the way to eradicate a disease was to vaccinate the entire population, Mass vaccination turned out to be insufficient. Henderson stressed the need for surveillance and containment, i.e. reporting and controlling of cases where when a case was identified, the sick person was isolated quickly and all the patient’s primary contacts (relatives, neighbours, co-workers) and secondary contacts (the contacts of the contacts) were vaccinated. The programme work was done by local public health workers in countries with the support of nine staff in the smallpox unit in Geneva and 150 international staff in the field. WHO staff served as a catalyst 5 .

The programme had to overcome many problems: lack of funds, unavailability of vaccine of adequate potency, bureaucracy in WHO, countries’ political and financial problems. National and international smallpox workers had to toil under gruelling conditions, often living in villages without electricity or running water.

In October 1977, a young man from Somalia named Ali Maow Maalin became the last human case of naturally occurring smallpox in the world – he survived. In

1980, WHO declared the disease eradicated 6.

Henderson’s leadership and determination were key to success with the support of the Director-General, H. Mahler. When the health minister of Ethiopia would not cooperate with him, Henderson went to the country and unblocked the situation by befriending the personal physician of the Emperor, Haile Selassie. When

Henderson was concerned that the Russians were supplying vaccine of insufficient potency, he travelled to Moscow and demanded better vaccine, violating orders from

5 Robin Maranty Henig, “35 Who Made a Difference: D.A. Henderson, Eradicating one of history’s deadliest diseases was just the beginning”, Smithsonian.com, 1 November 2005 http://www.smithsonianmag.com/people- places/35-who-made-a-difference Accessed 30 November 2014.

6 Henig. 5 his superiors who feared a diplomatic crisis 7 . He also by-passed clearance by

WHO Regional Offices when quick action was needed to support country programmes.

Henderson took a creative albeit controversial approach to the WHO headquarters bureaucracy and regional office structure. He established direct communication with regional office and staff. He maintained close personal contact with national and international staff and advisers. When not on duty travel, most week-ends would see his car parked in front of the WHO Geneva building.

In February 1977, Henderson left Geneva to become dean of Johns Hopkins

School of Public Health. In October 2001, he was appointed Chair of a new national advisory council on public health preparedness to better counter bioterrorist attacks.

He has received many awards and honorary university degrees in the USA and 14 other countries.

Again an iconoclast, Henderson countered conventional wisdom in 2002 by speaking against global efforts to eradicate polio 8

WHO still relies on the smallpox eradication success story as evidence that its global work and reach can achieve results. However it rens as the only example of the completed eradication of a specific disease.

Dr Henderson is considered a “real American hero” in his country.

Dr Jonathan Mann

Dr Mann, American physician and epidemiologist, headed the WHO Global

Programme on AIDS at its Geneva headquarters, from 1986 to 1990. He was born on 30 July 1947 in Boston, Massachusetts, USA and died on 2 September 1998 in a commercial air crash.

7 “Donald Ainslie Henderson, Henderson Wiped Out Smallpox”, Encyclopedia of World Biography, 2004.

8 Henig. 6

Mann earned his M.D. from Washington University in St Louis in 1974 and his

M.P.H. degree from the Harvard School of Public Health in 1980.

In 1975, he joined the US Centers for Disease Control and Prevention (CDC) in

Atlanta, GA, and was assigned to New Mexico as state epidemiologist. From 1984 to

1986, he moved to Zaire (Democratic Republic of the Congo) where a new AIDS programme was starting. He began collecting epidemiological, clinical and biomedical evidence on HIV and AIDS in an African context. Evidence shows that the AIDS/HIV pandemic started in the 1970s.

Mann joins WHO

Mann joined WHO in 1986 as head of a small Control Programme on AIDS within the Division of Communicable Diseases. Initially, Dr Halfdan Mahler, WHO’s

Director-General, considered HIV/AIDS to be a disease of developed countries 9 . He was persuaded by Mann that it posed a major global health threat. Estimates were that the disease would infect from 100,000 to 300,000 people by 1980. Last report from UNAIDS (2014) states that there are 35 million people living with HIV, new infections were 2.1 million in 2013, focusing on Nigeria, South Africa and Uganda 10.

About 1.5 million people died from the disease in 2013.

Under Mann’s leadership, the WHO Programme was soon expanded to become the

Special Programme on AIDS in 1987, and then the Global Programme on AIDS

(GPA). In 1987, Mann gave a briefing to the United Nations General Assembly, which led to the adoption of resolution 42/8 confirming WHO’s “essential global directing and coordinating role” in fighting the disease. The Programme expanded to become the largest single programme in WHO’s history. From 1987 to 1990,

9 Lee, 58-66. 10 UNAIDS report shows that 19 million of the 35 million people living with HIV today do not know that they have the virus”, UNAIDS press release, 16 July 2014. http://www.unaids.org/en/resources/presscentre/pressreleaseandstat Accessed 22 March 2015. 7 voluntary funding rose from around $18 million to 100 million, with staff at headquarters increasing from three to over 100. By 1988, GPA had established projects in over 170 countries, with the development of national AIDS strategies.

Mann believed that AIDS was not only a medical or scientific phenomenon, but also a social issue. He worked against discrimination against persons with HIV/AIDS who were refused employment, insurance, travel and immigration. He understood that infringement of rights caused by poverty and exclusion made people more vulnerable to the disease.

The Programme’s global strategy was unprecedented in international public health in that it specifically incorporated human rights principles. It engaged non-traditional partners – sex workers, homosexuals and drug users – to work with government officials and WHO staff in the Programme 11 .

The priority given to HIV/AIDS within WHO, the funds given to the programme, his inclusion of human rights and his unorthodox practices brought Mann into conflict with Dr H. Nakajima (Japan) who had succeeded Mahler as Director-General in

1988, and probably with rivals in the organization. Nakajima felt that the disease had been given too high a profile, at the expense of malaria, a bigger killer at the time – estimated mortality due to malaria was estimated at 584,000 in 2013 as against 1.5 million from AIDS. Mann’s public profile was lowered, the emphasis on human rights was reduced and administrative constraints were imposed on the Programme, leading to Mann’s resignation from WHO in March 1990, for “issues of principles and

“major disagreements” with Dr Nakajima.

11 “Jonathan Mann, Founder of the Health and Human Rights Movement”, Daniel Tarantola, Sofia Gruskin, Th. M.Brown and Elizabeth Fee, Am J Public Health, 2006, November; 96(11): 1942-1943. See also “A Tribute to Jonathan Mann: Health and Human Rights in the AIDS Pandemic”, L.O. Gostin, The Journal of Law, Medicine and Ethics, Vol. 26:3, Fall 1998, 256-258. 8

Mann then moved to the Harvard School of Public Health as a tenured professor and director of the International AIDS Center of the Harvard AIDS Institute. He left

Harvard at the end of 1997, accepting a position as the founding dean at a new school of public health at Allegheny University of Health Sciences, Philadelphia, Pa,

Mann died (with his second wife) in the 1998 crash of Swissair Flight 111, New

York/Geneva.

On 1 January 1996, the WHO Programme was replaced by the Joint UN Programme on AIDS, now sponsored by ILO, UNDOC, UNDP, UNESCO, UNFPA, UNHCR,

UNICEF, the World Bank, WFP and WHO. The creation of UNAIDS was considered as a major blow to WHO’s leadership over a global health issue 12 . During his two five-year terms of office, Dr Nakajima came under criticisms of mismanagement, but also for his treatment of Dr Mann.

As Dr Henderson, Dr Mann made direct communications with regional and country staff. Through his eloquent public speeches and his publications, he obtained general support for his programme. In his staff meetings, he inspired loyalty and hard work to a high degree from GPA staff.

Conclusion

There are probably many officials in the United Nations, in other UN agencies and in

WHO itself who are competent, hard-working and obtain results in their field. Most of them do not achieve public fame, and many probably do not seek it. Achieving public fame may be a target for attacks by governments, by internal rivals. Being considered as a rival by the head of a UN secretariat may be fatal to the famous

12 Lee, 62. 9 official’s career. In recent times, Sergio Vieira de Mello (Brazil) remains perhaps as the best known example of an outstanding UN peacekeeper, diplomat, and humanitarian figure still remembered in UN and human rights circles, after his death in Baghdad on 19 August 2003 with twenty-one other victims 13.

Both Dr Henderson and Dr Mann showed technical competence in their respective field of work. Their programmes had important public health relevance giving them priority over other competing programmes. They gave an expectation of achievable results within a set period. They were important to both industrial and developing countries, an essential element for obtaining the support of governing bodies.

They both had a strong personality, leadership skills, dedication to their work and determination to override technical, operational and bureaucratic obstacles. At key points, they took risks in breaking rules and overcoming hierarchical hurdles.

They both needed the Director-General’s support: when Dr Nakajima decided to change the priority previously given to AIDS, Dr Mann had no option but to leave

Yves Beigbeder

May 2015

13 See: “Sergio Vieira de Mello”, http://www.ohchr.org/EN/AboutUs/Pages/Vieira.aspx Accessed 22 May 2015, - “Remembering Sergio Vieira de Mello Ten Years After the Attack on the UN in Baghdad”, Carolina Larriera, The Huffington Post, 19 August 2013.