Mon, 03/19/2018 - 21:09

We sent three set of questions with multi choices to each of the three candidates in the upcoming May elections for the post of Director-General the World Health Organization: Dr Tedros Adhanom Ghebreyesus, presented by the Government of Ethiopia, Dr Sania Nishtar, presented by the Government of Pakistan and Dr David Nabarro, presented by the Government of the United Kingdom, Great Britain and Northern Ireland.

We asked ourself, in what order to present their answers? Alphabetically? Finally, we decided to present them in the order in which we received the answers.

By Garance Fannie Upham


Dr Tedros Adhanom Ghebreyesus
Dr Tedros Adhanom Ghebreyesus 


AMR-Times: As WHO DG, how would you first go about implementation on the GAPAMR, the Global Plan adopted in last year's World Health Assembly. In what order would you place priorities below and why?

1- Stewardship - better management of antibiotics in health care
2- Infection prevention and control, making sure health system don't propagate AMR
3- Surveillance in human and/or animal health 

Dr Tedros A. Ghebreyesus: The overall goal of the global action plan is to ensure continuity of successful treatment and prevention of infectious diseases with effective, quality and safe medicines that are accessible to all who need them and used in a responsible way. All three of these priorities are important to addressing AMR – and they need to be addressed in parallel because they are interconnected. We need surveillance to better understand the challenge we face and to know when a resistant pathogen is spreading or when a new one has emerged. Infection prevention and control can stop a pathogen’s spread. And meanwhile, better management of antibiotics is necessary to stall the development of antimicrobial resistance in the first place. We should also need to strengthen the efforts in terms of developing and abiding tothe stewardship framework for better management of antibiotics on humans, animal and agricultural products, and promotion of one health approach 

AMR-Times: How would you view AMR priorities in relation to Climate Change & Health and why?

Climate change means more extreme events notably flooding, which is more important:
1- Resilient health care systems?
2- Better water and sanitation infrastructure?

Dr Tedros A. Ghebreyesus: AMR and the health impacts of climate change are both in my leadership priorities as a Director General candidate. Neither is constrained by country, regional or continental boundaries. Both are truly global challenges. The commitment on sustainable development goals (SDGs) offers a unique opportunity to address our health challenges in a comprehensive and integrated manner. Ensuring universal health care should be the center of gravity for the implementation of not only the health objectives of the SDGs but also to all goals. This will help to strengthen resilient health system, with strong primary health care, effective public health emergency preparedness and response as well as addressing essentials of a healthy life including water and sanitation infrastructure. Because these issues supersede national and regional boundaries, the WHO can be a strong voice in combatting them. Over the past few years, there has been great progress on both issues, including the Paris Agreement on Climate Change and the GPAMR, and the WHO has done a great job keeping these issues on the agenda. WHO has to intensify its efforts and build inter-agency and inter-sectoralpartnerships to better understand and address the health impacts of climate change and enhance access climate financing instruments. The WHO is not the technical expert on all these issues, but I believe it can lead the way in breaking the silos among our development objectives and in forging new models to engage and collaborate across different stakeholder groups. 

AMR-Times: How do you envision working with not for profit civil society and will it be a priority for you,

1- to implement Universal Health Coverage, so as to strengthen means to face AMR?
2- to achieve TB & HIV control as ARV and TB drugs resistance is on the increase?
3- to manage NCDs, considering that cancer treatment is threatened by antibiotic resistance? 

Dr Tedros A. Ghebreyesus: Civil society is a critical stakeholder and partner in global health – it helps to hold us all accountable, brings new ideas, gives voice to the voiceless and marginalized, and acts as our greatest advocates when we do good work. If you look at many other, newer global health entities such as the Global Fund, GAVI and UNITAID, they include civil society as full partners. That is the new order for which WHO should also be aligned. WHO is somewhat different, as a member-state organization. But I believe that partnerships and collaboration, including those with civil society, will be critical for the WHO to achieve its mandate. The recently agreed Framework for Engagement of Non-State Actors should provide a systematic way to enhance and facilitate the civil society in the work of WHO without compromise to its role in standard and norm setting as well as protection from conflict of interest.

On the specific issues, in my view, all roads should lead to universal health coverage. Accordingly, I have made universal health coverage my highest priority. It is an ambitious goal, but it is one that can and must be achieved to create a healthier and more equitable world. Greater commitment to universal health care will help to develop and deliver affordable, effective, safe and quality drugs for diseases that disproportionately affect developing countries and vulnerable populations and remain poorly addressed owing to market failures.

Continuing to scale up treatment for HIV and TB – and addressing the growing rates of resistance –should be high on the agenda of our efforts in combating AMR. We have made tremendous gains on these diseases in the past few decades, and I’m gravely concerned that resistance will start to unwind that progress. In 2015, for example, the WHO estimated that there were more than half a million new cases of drug-resistant TB cases that require treatment but only 20% of them were treated. Even those treated they have about 50% treatment success rate. We cannot underestimate this crisis and we must do better to identify, track and manage these drug-resistantTB cases as part of our AMR efforts. 

Combating NCDs like cancer, heart disease, chronic respiratory diseases and diabetes is also one of my priorities for the WHO. We need to do this by scaling up evidence-based approaches to prevention, diagnosis, and treatment, encouraging healthy lifestyles and well-informed decisions, strengthening prevention and treatment of substance abuse and accelerating the implementation of the WHO Framework Convention on Tobacco Control. Here we can take what we’ve learned from treating communicable diseases for decades. 


Dr Sania Nishtar
Dr Sania Nishtar


AMR-Times: As WHO DG, how would you first go about implementation of the GAPAMR, the Global Plan adopted in last year's World Health Assembly. In what order would you place priorities below and why?

1- Stewardship - better management of antibiotics in health care
2- Infection prevention and control, making sure health system don't propagate AMR
3- Surveillance in human and/or
 animal health   

Dr Sania Nishtar: The next Director General is tasked with addressing the reality and urgency of the antimicrobial resistance crisis.  Doing so will entail being committed and accountable to the priorities outlined in the GAPAMR: to improve awareness and understanding of the problem through communication, education and training; to strengthen evidence through surveillance and research; to reduce incidence of infectious diseases, especially those less vulnerable to existing therapies; and to work with other global bodies including the FAO, OIE, the World Bank, and the private sector to estimate economic impacts and commit to sustainable investment in new tools to combat infectious disease in the face of this crisis.  

The role of the DG in implementing these principles entails engagement at global, national, regional levels and with a range of stakeholders to ensure that the WHO serves as a coordinating body, convener of evidence and source of synchronized guidelines and surveillance mechanisms to combat AMR.  Globally this will entail collaboration with other UN bodies, international economic institutions, G 7, G 20, G77, the FAO and the OIE to generate core training materials, convene expert committees and advocate for responsible national and international policies that support disease prevention and containment through robust surveillance and cooperation. 

In addition, the DG is charged with overseeing the development and endorsement of national level action plans and antibiotic stewardship policies by Member States that reflect important principles of multi-sector engagement, prevention as a priority, equity in access to preventive and curative measures, and the development and adherence to frameworks of incremental and measurable target setting and tracking.  More broadly, meaningful progress in the global effort to prevent and adapt to antimicrobial resistance will entail substantive systems reforms at various levels, something I have enacted and overseen during in my career thus far.

As the chief technical officer of the organization, the DG is also responsible for shepherding WHO’s important norms and standards role in relation to AMR; for example, guidelines for infection prevention control, list of critically important antimicrobials, and priority pathogen lists to guide R&D strategies. The DG must also oversee the consolidation of the Global AMR Surveillance System, and catalyze incentives for R&D where there are market failures. Overall the DG must exercise leadership to mobilize the needed multi-sectoral political commitment at the highest level and actions from the Member States and WHO partners in the scientific community and pharmaceutical industry.

In reference to the three priorities listed, it is crucial that they be executed in coordination with one another rather than be ranked sequentially. Prevention is a key tenet of the GAPAMR, but also a core function of the WHO in its mandate to promote the highest attainable level of health for all peoples.  Prevention and management of infectious diseases and their broader social and economic impacts cannot be prioritized without effective surveillance systems in place.  Similarly, promoting stewardship is impossible without robust surveillance system tracking disease agents, prescribing practices, and antibiotic consumption behaviors in different contexts.  These three priorities are therefore inextricably linked and it is the DG’s role to ensure they are implemented in tandem and in coordination with key stakeholders across borders. Finally, regarding animal health, I would like to underscore the importance of the so-called Tripartite, composed of the FAO, OIE, and WHO. I will fully support this collaboration.

WHO needs to technically support countries to develop and implement national plans and assist with the development of antibiotic stewardship policies. In close collaboration with FAO and OIE, WHO should support countries as they develop and implement their own national action plans on AMR. At the high-level meeting of the President of the UNGA on AMR there was an overwhelming political support to combat AMR. I will ensure words are put into action and will develop a clear roadmap with commitments. Under my leadership, the AMR program would remain a special initiative under the Director-General’s Office.

Tackling AMR necessitates action to address crosscutting issues in animal and human health, agriculture, food, and environment.

AMR-times: How would you view AMR priorities in relation to Climate Change & Health and why? Climate change means more extreme events notably flooding, which is more important:

1- Resilient health care systems 
2- Better water and sanitation infrastructure?

Dr Sania Nishtar: Climate change and the antibiotic crisis pose many parallel and overlapping challenges to global disease control and health promotion.  Climate change brings with it the threat of novel pathogens, changing epidemiology of existing ones, and an increasing number of events which may disrupt or weaken health systems. Resistance to available antimicrobials compounds these risks; outbreaks triggered by climate events will be more challenging to control, and management of AMR is heavily reliant on the integrity of integrated surveillance infrastructure.  Furthermore, climate change and AMR pose a joint risk to food security, with changing weather patterns and resistant microbes threatening the continuity of many existing farming and crop practices.   Taken together, these crises may compound one another’s impacts on health, and it is the responsibility of the global health community to identify areas for integration and overlap of preventive strategies and action plans endorsed by the WHO. 

Various areas exist in which the approaches and infrastructure needed to combat these two issues overlap, including outbreak prevention preparedness, water, and sanitation infrastructure, health systems strengthening, surveillance, and behavior change. Therefore, it is the role of the WHO to harmonize efforts across different sectors and ensure that prevention and adaptation strategies for both AMR and climate change are integrated into global health, development, and economic across sectors and regions. With regard to the question of whether resilient healthcare systems or better water and sanitation infrastructure is a greater priority, I would argue that both are crucial components of successful disease prevention & control, which is a core function of the WHO.  From an AMR perspective, water and sanitation are the first cornerstones of preventing AMR. Water and sanitation infrastructure are a core tenet of public health principles since the inception of public health work, bearing clear relevance to minimizing climate-related outbreaks. In particular reference to the issue of AMR, resilient health systems will be more instrumental to tracking, preventing and controlling the spread of resistant pathogens.  They are also necessary to help mitigate challenges that arise from climate-related migration.  For example, resilient and coordinated health systems data are of key relevance to minimizing the spread of disease arising from displacement due to climate events. The WHO must commit to working with other agencies in order to make sure that both of these strategies are prioritized to prevent and manage the healthcare crises posed by both climate change and antimicrobial resistance in the coming era. 

AMR-times: How do you envision working with not for profit civil society and will it be a priority for you to: 

1- to implement Universal Health Coverage, so as to strengthen means to face AMR 
2- to achieve TB & HIV control as ARV and TB drugs resistance is on the increase? 
3- to manage NCDs, considering that cancer treatment is threatened by antibiotic resistance

Dr Sania Nishtar: Having engaged with the issue of antimicrobial resistance from many different perspectives in my roles in both government and civil society, I believe that collaboration across these sectors will be crucial to better understand challenges and generating solutions that are both evidence-based and empirically informed.  It is critical that civil society is engaged and empowered to fulfill its role in helping to understand issues on the ground that relate to antimicrobial resistance.  Specifically, in reference to each of these issues:

1- Universal Health Coverage: Civil society groups are uniquely poised to inform international bodies such as the WHO on issues of equity and access, and often do so with a very different perspective than governmental agencies.  They serve a critical role in highlighting and uplifting the voices and experiences marginalized or stigmatized groups and drawing attention to the special needs of different populations.  As such, their voice is instrumental in implementing Universal Health Coverage, an initiative with equity, access, and non-discrimination at its core. 

2- TB/HIV: Chronic or long-lasting infectious diseases like tuberculosis and HIV pose salient challenges to our efforts to combat AMR due to the lengthy therapeutic courses and highlikelihood of not completing treatment.   In addition, they are often highly stigmatized and those suffering may be difficult to reach or reluctant to seek help or engage openly with medical professionals about appropriate treatment and risk control behaviors.  Civil society groups can help to address and report on issues like stigma, promote educational and behavior change materials, and engage with vulnerable groups with a level of access that government may not have. They may be more trusted by various actors within the community and therefore are vital to the holistic approach to promoting better management of these physically and socio-emotionally challenging conditions.

3- Antimicrobial resistance is a serious threat to the management of NCD due to the possibility of compromising safety during and after surgical procedures, sterility of hospital settings, and cancer treatment.  Currently, many initiatives and institutions that treat these as two unrelated issues, but given the threat to NCD control as well as the anticipated health systems strains that will occur in a context of AMR-driven infectious diseases resurgence, it is in the interest of all if disparate groups align their efforts more closely.  The WHO must pioneer and oversee more collaboration between infectious and non-communicable disease control programs in the coming era, both as a tool of preparedness for the new challenges AMR poses to both issues and as a platform through which to enact broad health systems strengthening.  In this respect, I would like to mention that I will also give voice to consumer groups because they are instrumental in pressing the food industry to produce antibiotic-free food.

More broadly, similar to the function of the WHO, civil society plays a crucial role in representing, working with and brokering communication between very different stakeholders whose buy-in and collaboration is needed to combat AMR.  For example, civil society groups support substantive changes to policy and practice through their ability to engage with the private sector in a different manner than governments or elected officials can.  The efforts to curb antimicrobial resistance must entail accountability and regulation of pharmaceutical practices, and leaders in the private industry as uniquely poised to invest and innovate in novel diagnostic and therapeutic strategies to monitor battle resistant agents.  As such, civil society’s engagement with the private sector will be a key tool in the unified movement to combat AMR.


Dr David Nabarro
Dr David Nabarro


AMR-Times: As WHO DG, how would you first go about implementation on the GAPAMR, the Global Action Plan adopted in last year's World Health Assembly.

In what order would you place priorities below and why?
1- Stewardship - better management of antibiotics in health care
2- Infection prevention and control, making sure health system don't propagate AMR
3- Surveillance in human 
and/or animal health

Dr David Nabarro: The GAPAMR serves as a blueprint and sets out five strategic objectives:

  • to improve awareness and understanding of antimicrobial resistance;
  • to strengthen knowledge through surveillance and research;
  • to reduce the incidence of infection;
  • to optimize the use of antimicrobial agents; and
  • develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

WHO has a unique role to play – leading and coordinating on awareness raising, political mobilization, consensus building, fostering partnerships and monitoring progress. The issue has been given highest priority with a Secretariat for Antimicrobial Resistance located in the Office of the Director-General.  This coordinates work on AMR across WHO’s different country offices, regional offices and headquarter departments.  

WHO collaborates with FAO and OIE to support a one health approach to implementation, taking necessary actions under each of the five objectives in the GAP and supporting countries in developing and implementing national action plans on AMR.   The prioritization of actions will depend on what countries need and what support they seek.  

The Political Declaration at the UN General Assembly High-Level Meeting at UN headquarters on the 21st September reflected an agreement to act among the leaders of 193 countries.  The declaration stressed the urgency of action, underlined the need for a multi-sectorial approach and requested the Secretary-General of the UN to establish an interagency mechanism to drive progress. WHO’s work will reflect the directives in this political declaration, supporting the Member States as they take forward National Action Plans.  This means assisting with awareness raising and making the economic case; analyzing the progression of AMR through surveillance, infection prevention and control; and optimizing the use of antimicrobial agents.  Each objective of the Global Action Plan will be important within every country.  The actions to be prioritized will depend on the way in which the situation in a country is prioritized by the national authority within its National Action Plan.   

In many countries, the main threat to people’s health and well-being is that they lack access to effective antimicrobials.  This may be a greater threat than microbes being resistant to medications.  Hence the need to ensure that all people are able to access quality health care when they need it and that barriers to access (including access to antimicrobials) are removed.  

On stewardship: Profligate use of antibiotics can stimulate the emergence of bacteria that are resistant to antibiotics within humans, animals, and environments.  Antibiotics are valuable and reducing unnecessary use - in all settings – is key to maintaining their potency and preventing AMR.    This can be achieved through evidence-based prescribing aided by means for understanding which bacteria are associated with infections.  This underlines the importance of developing, disseminating and using reliable, rapid and low-cost diagnostic tools for use in animal and humans to optimize the use of antimicrobial agents in health care.   

Multilateral organizations, including WHO, work with national authorities to encourage (a) better training and supervision of those who prescribe and use antibiotics so as to increase adherence to evidence-based treatment regimes, (b) quality assurance measures to prevent prescription and use of substandard antibiotics, and (c) the restriction of antibiotic use in human and animal health to situations in which they are clinically indicated.   

On Infection prevention and control: The need for antibiotics can be reduced through lowering the incidence of bacterial infection – through preventing infection.  This means implementing practices that prevent the spread of bacterial infections and for bringing disease outbreaks under control – otherwise known as Infection Control. If infections are uncontrolled there is an increased likelihood that infections resistant to treatment will spread. especially during outbreaks of infectious diseases. Effective infection prevention and control (IPC) practices are particularly important within units (hospitals and clinics) offering health care. People (including health workers) who move between patients without disinfecting themselves can unwittingly contribute to the spread of resistant organisms, lengthening illnesses, prolonging hospitalization, and increasing costs. Hospitals are important centers for the dissemination of microbes resistant to treatments (AMRMs): healthcare workers may face an increased risk of acquiring resistant infections. Other locations where people are in close contact – eg prisons – may also be important for disseminating AMRMs. Sanitation and hand washing, as well as food and water safety, injection safety and safe sexual practices are central elements of infection control.  They help reduce the spread of AMRMs.

On Surveillance: We can only respond well to a disease threat if we know what it is, where it is, how big it is and how it is progressing.   This is best done through standardized and reliable information – often referred to as systems for surveillance of AMR.  They provide early warnings of emerging AMR threats and long-term trends.  They guide policy & enable those involved to make timely public health interventions.  They enable health professionals to make informed clinical decisions and this leads to better outcomes. WHO has the legitimacy and systems needed for conducting global surveillance based on surveillance data provided by individual countries.  The Global Antimicrobial Resistance Surveillance System (GLASS) encourages a standardized approach to collection and analysis of data from patients, laboratories, and populations: it also helps with the production and sharing of national information on AMRM.  This then provides the evidence base for decision making and for advocacy among both professionals and the wider public.  

On Access: WHO estimates that 30% of people within poorer countries – and 50% of persons in Sub-Saharan Africa - do not have access to essential and effective medicines.  Governments seek to improve people’s access to medicines of quality, to prevent counterfeits from entering the supply chain and to encourage responsible prescribing of antimicrobials.  

AMR-times: How would you view AMR priorities in relation to Climate Change & Health and why?

Climate change means more extreme events notably flooding, which is more important:
1- Resilient health care systems?
2- Better water and sanitation infrastructure?

Dr David Nabarro: People’s health will increasingly be affected by consequences of climate change. These include the direct impacts on people’s lives as a result of extreme events such as flooding and heatwaves, to indirect health effects as a result of food insecurity, changes in patterns of vector, food and water borne diseases, damage to infrastructure and services, violent conflict and migration.  

The risks can be reduced through action to limit climate change – specifically worldwide transition to low carbon economies. This means reducing atmospheric emissions of substances which contribute to climate change: such actions often have direct benefits for people’s health (more activity, better diets, and cleaner air.  All of these changes will prevent non-communicable disease. 

The consequences can be reduced through increasing the resilience within societies under threat.  This includes reducing the risks associated with adverse weather events through strong public health services (drinking water and sanitation, immunisation and child health services), infrastructure to reduce the impacts of extreme weather events, and poverty alleviation. 

There are a number of links between the challenge of AMR and the challenge of climate change for health. Climate change is expected to alter the incidence and distribution of infectious disease, through both direct and indirect mechanisms, and increases in the global burden of infectious diseases will have a knock-on effect on AMR.

AMR-times: How do you envision working with not for profit civil society and will it be a priority for you,

1- to implement Universal Health Coverage, so as to strengthen means to face AMR?
2- to achieve TB & HIV control as ARV and TB drugs resistance is on the increase?
3- to manage NCDs, considering that cancer treatment is threatened by antibiotic resistance?

Dr David Nabarro: Civil society is already significantly engaged in HIV and TB drug resistance but except at high-level moments (e.g. UNGA) there has been limited engagement to date on AMR.  There is room for greater CSO involvement in the AMR agenda. Civil society has a role in service delivery (including advocacy for quality services, stewardship of service delivery and support for treatment that adheres to best practice); accountability (following up on national and global commitments and advocacy/awareness raising.  

1- UHC and AMR: Progress towards Universal Health Coverage is necessary to address AMR as stronger health systems and basic services encompass both direct and sensitive AMR action. AMR should be part of the broader UHC agenda and mainstreamed into health systems strengthening with some elements requiring special attention (e.g. prescriber behavior, laboratory surveillance and diagnostics). Important to avoid AMR becoming yet another vertical issue (we know that CSO networks and action often follow the funding). Patients need to be able to complete treatment courses (compliance link to affordability) and to ensure governments progressively implement UHC. WHO DG should ensure that the UN follow- up mechanisms such as the Inter-Agency Coordination Group on AMR include a strong civil society voice.  

WHO’s global monitoring report on UHC produced in 2015 examined access to essential health services throughout the world — specifically family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and availability of both drinkable water and sanitation.  More than; 

  • 400 million people lack access to at least one of these services.
  • across 37 countries, 6% of the population was tipped or pushed further into extreme poverty ($1.25/day) because they had to pay for health services out of their own pocket. 
  • 17% of people in these countries were impoverished, or further impoverished, by health expenses. 

Through civil society, citizens can shape their health, seek good quality services and help to manage and account for them. Through participatory budgeting, monitoring public expenditure and community-based monitoring they can enable citizens to partner with governments and service providers.

2- HIV and TB treatment and AMR:  In HIV treatment Anti-Retroviral Therapy (ART) scale-up is one of the greatest public health achievements of the last decade. Since 2012 there has been an increase in reports of elevated HIV drug resistance (HIVDR):  to first-line ART. In some cases, the percent of HIV-positive people with HIVDR prior to their treatment has reached 10%. As many as 35% of people who have had previous exposure to ART exhibit resistance to one or more ARVs when they start off. Civil society plays a vital role in supporting treatment adherence and preventing resistance in HIV treatment programmes.   

In 2015, there were an estimated 480,000 new cases of multidrug-resistant TB.  There is a very strong alliance of lobby groups and scientists engaged in the agenda and drawing attention to MDR-TB. Some implement services, some advocate and some do both: Whilst we acknowledge the urgency of addressing TB drug resistance, we would not want to see other AMR research pushed back as a result. Attention to this interaction would maximize the opportunities to detect and to treat both non-communicable and infectious diseases through alert primary and more specialized health care services. For example, tobacco smokers and people with diabetes, alcohol use disorders, immunosuppression or exposure to second-hand smoke have a higher risk of developing tuberculosis. As the diagnosis of tuberculosis is often missed in people with chronic respiratory diseases, collaboration in screening for diabetes and chronic respiratory disease in tuberculosis clinics and for tuberculosis in non-communicable disease clinics could enhance case-finding.”

3-Non-communicable disease and NCDs:  There is a higher risk in the poorest and most vulnerable people of experiencing both communicable and non-communicable diseases concurrently: this results in increased threats from antimicrobial resistance. The threat, and the benefits of integrated management, are recognised in the Global Action Plan for the prevention and control of NCDs, which also highlights the benefits of integrated management: There is also increased susceptibility to infection in people with pre-existing non-communicable diseases: hence the importance of integrated disease management in primary and referral health care.