(Helen Branswell – StatNews)

Representatives of countries from around the globe will get down to the task of electing the next leader of the World Health Organization on Tuesday.

Here at STAT, we’re not making any bold prognostications on who will be selected to take over the helm of the global health agency from outgoing Director-General Margaret Chan, who has served two terms and cannot run again. The only prediction we feel relatively safe making is that in the halls of the WHO’s Geneva headquarters, Tuesday may be a very long day.

This election — the first time the WHO’s entire membership will be involved in selecting a director-general — involves secret balloting. Few if any countries have tipped their hands about how they are casting their votes.

 “I certainly wouldn’t say that it’s clear which way the race is going to go. Not from my perspective,” Suerie Moon, director of research at the global health center of the Graduate Institute of International and Development Studies in Geneva, said of the race.

Previously WHO’s executive board — a rotating committee of 34 member countries, serving three-year terms — chose the director-general and sent its selection to the entire WHO membership for rubber-stamping. Many observers welcome the shift to the all-member vote. But some wish the changes had gone further.

“I look at this as kind of a symbol of what broader WHO reforms have been like. … It’s not going anywhere near as far as it needs to, but, you know, it’s a step in the right direction,” said Dr. Ashish Jha, of Harvard’s T.H. Chan School of Public Health.

“It should be an open and transparent process. Everybody’s vote should be public.”

The WHO’s member countries will make their choice from three candidates, a short list that was winnowed down from six people who originally sought the job. The candidates are, in alphabetical order:

Tedros Adhanom Ghebreyesus, 52, from Ethiopia. Tedros, as he is known, is a former foreign affairs minister and health minister for his country. He is not a physician but has a doctorate in community health.

David Nabarro, of Britain. Nabarro, 67, has spent much of his career at the WHO and the United Nations. He is currently special adviser to the UN secretary general on sustainable development and climate change.

Sania Nishtar, of Pakistan. A cardiologist, Nishtar, 54, was minister of health in a caretaker government in 2013 and has a lot of national and international experience in the civil society sector.

All three have been crisscrossing the globe trying to garner support, posting pictures of themselves hither and thither on social media.

Late in the campaign Tedros has found himself the focus of the mainstream media as well, with first the New York Times and then other organizations reporting on allegations that under his leadership Ethiopia covered up several deadly outbreaks of cholera, reporting the epidemics to the WHO by the vaguer term “acute watery diarrhea.”

The accusations were leveled by global health law expert and professor Lawrence Gostin, of Georgetown University’s O’Neill Institute for National and Global Health, who is advising Nabarro’s campaign.

Tedros denied the cholera charge. And this week he got a vote of support from what might be a surprising source — Dr. Tom Frieden, the former director of the Centers for Disease Control and Prevention. That Frieden chose to get involved is interesting; he represented the US at the WHO executive board meeting in January that chose the final three candidates.

He won’t be attending the World Health Assembly, having delegated the US voting position to Dr. Mitchell Wolfe of the CDC, who is acting assistant secretary for global affairs. Wolfe will be traveling to Geneva with voting instructions. “Many parts of the US government have input into the US preference, including both the State Department and the Department of Health and Human Services,” Frieden said.

Frieden wrote a letter to the Times arguing that many countries report cholera to the WHO as acute watery diarrhea. It allows them to report without requiring laboratory confirmation.

“Do I wish every country reported cholera as cholera? Of course. But was any harm done reporting cholera as acute watery diarrhea? No,” Frieden told STAT.

Frieden’s letter lauded Tedros’s reform of Ethiopia’s health system, though stopped just short of endorsing his candidacy.

The US government has not indicated who it is supporting for WHO director-general, and Frieden won’t reveal who he supported when he cast the US vote.

Tedros is considered a front-runner in some circles, having entered the race with the support of the entire African Union. There has been talk for some time that it is “Africa’s turn.” Previous director generals have come from North and South America, Europe, and Asia; an African has never held the post.

But the way this vote will be held — in secret, with initial rounds of voting requiring a two-thirds majority to win — means the outcome cannot be taken for granted, observers say.

“It’s very hard to predict what’s going to happen, with the voting where Cook Islands has the same vote as China does and they’re going to go into rounds of closed voting,” said Dr. Seth Berkley, CEO of Gavi, the Vaccine Alliance, a public-private partnership that helps low income countries purchase vaccines.

“I have my own guesses, but this is not one where I feel like I really, really am certain about what’s going to happen.”

Horse trading and strategic voting are almost certainly part of the process and add to the unpredictability of the outcome.

Consider what happened when the executive board met in January to select the three-person shortlist from the six people who had put themselves forward for the job. On the first ballot, a senior WHO official from Italy, Dr. Flavia Bustreo, came second, a single vote behind the leader. On the next ballot, Bustreo was last — and knocked out of contention.

On both ballots, Tedros was first.

The voting starts Tuesday afternoon. To be successful in the first or second round, a candidate must get two-thirds of the votes cast. If no one makes it over that high bar in the first round of voting, the candidate who got the lowest number of votes is dropped from the ballot.

If there’s a second round of voting, two-thirds of the votes cast remains the magic number. If neither candidate attains it, a third round will be held; at that point a candidate would need 98 votes — a simple majority of the WHO’s 194 member countries to win.

If neither can secure that number, a final round of voting will be held. Winning a majority of the votes cast would earn the position at that point — and indicate the globe is badly split about who should lead the WHO.

Under WHO rules, the right to vote is tied to having paid WHO dues; any country behind by the equivalent of two years of dues cannot vote.

Six countries — Central African Republic, Comoros, Guinea, Guinea-Bissau, Somalia, and Ukraine — definitely will not vote in this election. Four others — Afghanistan, Burundi, El Salvador and Venezuela — could lose the right to vote Tuesday if they don’t make payments before then.

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* Originally published on May 22, 2017 on The STAT