Be careful what you wish for. That is what I would tell Thomas Frieden, if ever I had an opportunity to talk to the distinguished director of the US Government’s Centers for Disease Control (CDC). While the failures which led to the Ebola epidemic must be addressed and most certainly require difficult changes, we should avoid launching the pendulum too far in the opposite direction. Over-correction can be just as dangerous as doing nothing. (Perhaps even worse if, in the long run, failed change undermines the very case for change itself.).
Speaking as the executive board of the World Health Organization voted to overhaul the organization, here is what Frieden said: “Too many times the technical is overruled by the political in W.H.O. We have to reverse that.” His comments follow the generally accepted observation that the bungled response to the outbreak was in part due to the poor quality of WHO staff in West Africa. Political appointees rather than officials with proper qualifications.
I’ll start with the obvious: Frieden appears to be right. But there is a mistaken underlying assumption – that health, disease, pandemic response constitute primarily technical challenges. This overlooks the degree to which these issues are profoundly political. So: true enough that political savvy can neither replace nor overcome a deficit of technical understanding. Even worse, what of situations where the so-called political appointees lack political savvy, meaning where they are appointed for reasons of political loyalty and ties rather than political acumen? That’s a lose – lose situation.
But Frieden’s comment ignores the opposite risk. All the technical savvy in the world may amount to very little when it hits the political wall. Better qualified WHO appointees in West Africa may have recognized much earlier the threat posed by rising Ebola cases, and may have been less concerned with offending local political sensitivities, but there would have been plenty more hurdles to cross, some of them sadly and resolutely political. Remember, before they felt the threat themselves, the greatest powers in the world chose not to respond to Ebola in this strategic backwater of a region.
My instinct tells me that Frieden comprehends this quite well, and he may be one of those rare individuals who blends technical qualifications with a significant level of political interest and ability. That is not a common combination. A case in point: the bi-annual meetings of the Executive Directors of the various MSF sections. For the six years I was ED, there was never a time when more than one of the nineteen EDs was a doctor (though we often had a number of ex-lawyers), or more than one of the operational directors, and very few of the heads of mission. Throughout the executive level of MSF, from project coordinator to director, one finds few medically qualified personnel sitting in the hierarchy of decision-makers.
This is not the place for an analysis. Suffice it to say that (1) from security management to human resource management to negotiated access, running effective emergency medical missions in places like Sudan or Haiti requires more than medical know-how and expertise; and (2) the organization has built substantial in-house medical expertise across the spectrum of its areas of intervention. But the problem highlighted by Frieden’s quote is easier to describe than solve. In terms of the political and the technical, integrating those two bodies of knowledge, experience and focus posed a consistent challenge within MSF, and we struggled with various policies aimed at improving organizational structure and culture.
The Executive Board of WHO proposes what we sometimes termed “remedicalization” in MSF. The goal is clear: ensuring that Frieden’s “technical” sufficiently nourishes WHO analysis, decision and action. Sticking technical people into what are often politically charged jobs, though, may simply create the next crisis, the one where the pendulum has swung too far.