- Associated Press - Tuesday, May 23, 2017

LONDON (AP) - As the World Health Organization struggled to coordinate vaccine production during the 2009 swine flu pandemic, its director-general met with Vladimir Putin, then Russia’s prime minister, during an official visit to Moscow.

Dr. Margaret Chan commended Russia’s public health achievements and asked if the country might be willing to make a cheap vaccine for use in developing countries. WHO could test it and if approved, the shot would help the poor and vulnerable, Chan suggested.

Putin hesitated, saying he wasn’t sure there would be a sufficient market. He then noted a precipitous drop in the number of Russians employed by the United Nations health agency, from 52 to 17. Could Chan look into the situation, the prime minister asked?

Chan promised to consider the matter, according to internal notes of her June 2009 trip obtained by the Associated Press.

“She admitted that very few Russian nationals are now at senior positions in WHO,” the notes state, going on to refer to “a need to discuss how to encourage them to apply.”

During her decade-long tenure as WHO’s leader, Chan has often described herself as a “servant” of the agency’s 194 member countries. She says she accomplishes more with stern, behind-the-scenes diplomacy than with public criticism. But confidential notes detailing her work trips show that even in private, Chan, whose successor will be chosen Tuesday, sometimes was more inclined to appease heads of state than to challenge them on health issues.

WHO’s member countries will be choosing her successor from three candidates , all of whom have pledged to hold the agency to a higher standard of accountability.

Health experts said it wasn’t surprising Chan met with leaders such as Putin, but said WHO should be transparent about the purpose and outcome of the encounters. Chan’s meeting schedule was not public, although WHO published some of her speeches.

“The public has an absolute right to know if there’s even a whiff of double-dealing or trading favors,” said Lawrence Gostin, director of the WHO Collaborating Center on Global Health Law at Georgetown University.

The job of directing WHO carries exceptional power, from declaring when a health crisis has evolved into a global emergency to signing off on medical recommendations that affect billions of people. In juggling competing demands from constituents - including member countries, agency staffers, other U.N. heads and private partners - the job requires political savvy as much as medical expertise.

Chan had a reputation for both before she was named director-general. She was credited with helping avert a possible flu pandemic in 1997 while serving as Hong Kong’s health director by ordering the immediate slaughter of all of the territory’s chickens. Her willingness to share crucial details of the emerging outbreak of Severe Acute Respiratory Syndrome, or SARS, several years later, also drew respect from health officials struggling to get details from China.

That ultimately led to a position at WHO’s Geneva headquarters, where she assumed the top job in 2006 and has been lauded for her willingness to confront major problems in the nearly 30-year effort to eradicate polio, including why the project keeps missing its target.

Her administration was tainted, though, by WHO’s botched response to the biggest Ebola outbreak in history in 2014, when she delayed declaring a global health emergency for fear of upsetting the three affected West African countries.

Chan’s multiple visits to authoritarian countries have raised some eyebrows, since no obvious health crises prompted the trips and spending time with leaders with patchy human rights records might have compromised the agency’s integrity.

In April 2010, she led a delegation to Pyongyang, North Korea. After applauding the government’s “notable public health achievements,” including its “excellent” tuberculosis treatment and “good immunization coverage,” Chan opened the telemedicine facilities at the Kimanyu hospital that WHO helped support.

She also extolled North Korea’s 100 percent literacy rate during the visit and said the country had enough doctors and nurses.

A report published by Amnesty International later that year, however, described health care in North Korea as “a horror.” It said that understaffed hospitals didn’t have sterilized needles and that some patients were forced to have surgery without anesthesia.

With such basic gaps, some critics said it was unusual Chan would have backed a pricier intervention like telemedicine.

Chan heard from staffers at a hospital outside Pyongyang about medicine shortages. Employees there told her they relied on treatments derived from herbs, “which they themselves collected in the mountains,” notes from the trip state. The hospital was reportedly “very pleased” when WHO promised to donate some bicycles.

Three years later, WHO’s representative to North Korea, Yonas Tegegn, confirmed in an email that WHO would be giving the country another $400,000 worth of telemedicine equipment and support, as well as considering a request to help fund a documentary promoting the project.

Chan twice visited oil-rich Turkmenistan, a nation in Central Asia that Human Rights Watch has called “one of the world’s most repressive countries.” During the 2014 and 2015 trips, the WHO leader hailed Turkmenistan’s high immunization rates and gave President Gurbanguly Berdymukhamedov, who rewrote the Constitution so he could rule for life, a special health award.

A UNICEF report in 2014 found that child death rates were high in Turkmenistan and noted a worrying rise of vitamin A deficiency in children.

Dr. Peter Piot, a former head of the U.N. AIDS agency, was puzzled why Chan visited North Korea and traveled to Turkmenistan more than once.

“She can go to any member country, but to go back to a country where there are major human rights violations without an obvious health reason is strange,” Piot said.

While dealing with dictators is difficult, U.N. agency directors must not shrink from difficult discussions, he said. Piot described numerous uncomfortable situations he faced at the height of the AIDS epidemic while discussing homosexuality with African leaders such as Zimbabwe’s notoriously anti-gay Robert Mugabe.

After Chan’s visit to Moscow in 2009, it was reported that Russian vaccine makers started making swine flu shots. A report on WHO’s staffing for last year indicates there were 23-32 Russians working there. In 2012, Chan appointed Dr. Oleg Chestnov, a Russian national, to run the department overseeing non-communicable diseases and mental health.

China was one of the countries Chan visited most often during her directorship; she is a Hong Kong native and holds a Chinese passport.

Chan frequently met with China’s top leaders, including President Xi Jinping. Her trip reports detail numerous instances of her congratulating China for its health advances, including “the wonderful work done so far in terms of (tuberculosis) control.” China has one of the world’s biggest TB epidemics.

Following a state banquet in 2012, Chan also thanked China for nominating her for a second term at the World Health Organization’s helm and reiterated the agency’s commitment to the One China policy, which does not recognize Taiwanese sovereignty.

Earlier this month, WHO said that in keeping with U.N. policy, which requires sovereign status for membership, Taiwanese observers would not be invited to the annual World Health Assembly for the first time since 2008. The agency did not give a specific reason.

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Jamey Keaten in Geneva contributed to this report.

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This story has been corrected to say that Chan’s successor will be chosen Tuesday, not that she will leave office. AP Photos.

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