PROFILE

On Aug 23, 2002, WHO Director-General, H.E. Gro Harlem Brundtland shook the international health community by announcing her decision not to stand for a second term of office. The assumption that she would stay on as head of the UN health agency had been so strong. By the Nov 19 deadline, Ismail Sallam was among the nine distinguished candidates in the marathon for the post. These are (alphabetically):

In the booklet prepared for Sallam's nomination, the Egyptian government outlined his credentials for the post as follows:

“Professor Sallam's professional career is distinguished by a longtime involvement in international health and development-related issues. He served his country as Egypt's Minister of Health and Population from 1996 until 2002. He was appointed to this post because his experience in the health-policy arena at the national and international level allowed him to acquire a precise view of the health-related challenges and problems facing, not only Egypt, but also many other countries. Internationally, his active involvement in the WHO Governing Bodies, the Arab League, the Organization for African Unity (OAU) and South-to-South Partners, has familiarized him with both the strengths and the weaknesses in the structure and performance of the WHO, as well as the global health community.”

On January 28, 2003 the Executive Board (EB) of the WHO (chairman Kyaw Myint, Deputy Minister of Health of Burma) will vote for the new reformer and modernizer of the WHO. The EB is composed of the six following regions:

The Lancet has been covering the election campaign in depth, starting with a Special Report summarizing WHO's structure and electoral process since 26 October 1996 (www.thelancet.com) and fostered a greater debate about the direction of global health in the 21st century and WHO's role in steering the best course. To join in the debate, we invite readers to send in their comments (e-mail: whodg@lancet.com). All messages sent to this address will be posted on The Lancet website each week. Interestingly, the debate heated up when the following letter was posted in the November 30 issue of the Lancet by Prof. Hamdy El Sayed, an international cardiac surgeon and chairman of the Egyptian Medical Association for 15 years, in support of Prof. Ismail Sallam.

The Honorable Sheik Tantawy, H.E. Prof. Sallam, Pope Shenuda and
Prof. Hamdy El-Sayed during a campaign to eradicate blindness in Egypt.

Following Hamdy El-Sayed's letter, the Lancet journal published numerous correspondences supporting the candidacy of Ismail Sallam for the office in later issues. Some of these will be presented at the end of this article. Click here to read these letters.

With the strong support of President Mubarak and letters of support published in the Lancet to the nomination of Prof. Ismail Sallam as Director- General of the WHO, he seems to have emerged to the frontline of the competition to succeed the distinguished Dr. Brundtland. In order to understand why he is receiving global support, his outlined visions are key.

Dr. Sallam will base his leadership of the WHO on the premise that health is the basic unit with which the progress of any development should be measured. Therefore, the right to healthcare must be protected in all countries, since health holds the key to the prosperity of any nation and of the global community as a whole. Health issues in every country must be envisioned through a holistic, and hence resource-efficient, strategy for development that takes into account social, economic and political dimensions.

Dr. Sallam envisages the need to maintain health promotion through Healthy People Initiative and disease prevention as a basic element of human rights. Such a step is critical, not only for its moral significance, but also because it presents a fundamental prerequisite for sustained development. Health-for-all has been a longtime WHO goal. Although much has been done in this regard, there still remains a big gap between policy and reality, which hinders the fulfillment of this noble, yet essential, obligation. Alleviation of disparities in health promotion must be specifically tackled in order to guarantee the elimination of any sources of discrimination inside healthcare systems.

On a humanitarian level, Dr. Sallam will direct a WHO that abates the suffering of people in countries under war, natural disasters, poverty, or sanctions. Health should always be utilized as a benevolent channel that brings about development and peace.

Dr. Sallam believes that health and human security, and human rights are closely interconnected. Health security should be viewed as an integral part of the overall human security.

· Professor Ismail Sallam’s [MD, FRCS Ed & Eng, FACS, FACC, FICS, Ph.D, (Glasgow), FRCSP Hons (Glasgow)] career has been distinguished by an unconditional commitment to social justice and rallying political support for worthy causes.

· He formulated several leading groups for community participation in immunization and other health preventive national programs. He was even then dedicated to humanitarian and voluntary charitable work, and he chaired three NGOs that worked on raising the health and social conditions of disadvantaged groups in remote Egyptian areas. He contributed to the success of an initiative, which created an efficient blood donation system in Cairo in affiliation with an NGO.

· A politician as well as a doctor, in 1985, he was chosen Chairman of the Health, Environment and Population Committee of the National Democratic Party which contributed to shaping Egypt’s Health Policy. He contributed to the United Nations International Conference on Population and Development (ICPD) meeting in Cairo in 1994 . He served as a member of the Egyptian Parliament for over 15 years and as Chairman of the Health, Environment and Population Committee. In 1992, he was chosen majority leader of the Consultative Assembly (Senate).

· He devoted a large part of his life in academic and applied research both in medicine and public health. Sallam is the author and co-author of more than 250 scientific publications.

· During his 6-year term as Minister of Health and Population (1996 –2002), he changed the image of Egyptian health care. His vision was translated into a Health Sector Reform Strategy that was based on elimination of disparities within health services institutions. He identified several important obstacles that hindered the improvement of the health and welfare of the Egyptian people.

2. Health-for-All was one of the main goals of Health Sector Reform Programs, which set primary healthcare as its main focus.

3. A package of services was introduced and made accessible to the whole nation. A “Family Doctor Approach” was implemented and outreach programs extended health services coverage to remote population groups through mobile clinics.

4. Emphasis was given to preventive care, which became an integral part of all programs.

· He provided preventive medicine with strong momentum. This included various national programs for serious infectious and non-infectious diseases. He launched the Healthy Egyptians 2010 Initiative, which is an agenda for health promotion, maintenance and disease prevention for the 21st Century. This in turn, resulted in significant improvement of Egypt’s key health indicators over the last five years enabling Egypt to make a remarkable leap to rank 43rd on the index of health performance. The index reports how efficiently health systems translate expenditure into health as measured by disability-adjusted life expectancy (WHO, 2000).

· When he recognized the vital role, which civil society can play in public policy, decision-making, research, advocacy, education, training, monitoring and evaluation, he established in each governorate a consortium of the local NGOs that worked with the Ministry of Health to provide an integrated response to local health needs of various communities.

· When he recognized the importance of information technology, he encouraged studies and research in all health fields in collaboration with local and international organizations. Information technology and Internet facilities were introduced to decision-making support, enhancing the health information systems.

· He is a firm believer that no comprehensive development could be achieved without attaining full gender equality in terms of maximizing women’s capacity to participate freely and effectively in economic, social, political and cultural development. In a unique initiative to promote women’s health and to bridge the gender gap, over 1000 women health clubs were established in underserved areas to deliver comprehensive social and medical reproductive health services. Maternal mortality had fell by 55% over the last 7 years (MOHP, 2000), reflecting the rise in quality of reproductive health services. Prof. Sallam was determined to tackle gender-inequality inside underprivileged groups. In this regard, he took important and crucial decisions, including the issuing of a historical ministerial decree abolishing Female Genital Mutilation (FGM).

· One of Dr. Sallam’s greatest achievements was the success of his commitment to encourage international cooperation. His international contacts aided the Ministry in obtaining greater sponsorship from major international organizations and assistance from several donors, speeding up the pace of his proposed reforms. Dr. Sallam succeeded in doubling the funding for his health budget over the last two years in office. He raised over 3 billion Egyptian pounds as well as a charitable fund which reached 0.5 billion Egyptian pounds.

· He was elected Chairman of the Executive Board of Arab Ministers of Health at the Arab League for three consecutive tenures. During the six years of his chairmanship he brought about major changes that enhanced the level of multilateral cooperation between Arab health ministers. With the cooperation of the Arab Ministers, they succeeded in formulating regional strategies for health in the Arab world. Several technical committees were formed, contributing to greater sharing of information and resources among Arab countries. Among important achievements was in the area of pharmaceutical cooperation whereby the Arab Pharmaceutical Information Center was established in Egypt and is considered a masterpiece in information and documentation.

· He organized the first Pan African Ministerial Conference in Cairo, in June 1998. The Conference brought about a consensus on African health challenges such as control AIDS, malaria, nutritional disorders and other endemic diseases. The event also helped identify common priorities, in the areas of training, research, and formulated a blue print for cooperation at the regional level. Dr. Sallam was also elected Chairman of the Sixth Conference of African Ministers of Health, of the Organization of African Unity (OAU) member states, which was held in Cairo in October 1999.

· Prof. Ismail Sallam has actively contributed to the WHO activities over a number of years.

2- He chaired the second meeting of the Directors General’s Task Force on Malaria Prevention and Control in Cairo in October 1997. He supported the efforts of the African Ministers of Health in tackling malaria through the mobilization of all resources toward a common goal.

3- He was a member of the Executive Board of WHO during the period from 1996 till 1999 and from January 2002, he was selected for membership in the Auditing Committee. He led many of the discussions on vital health issues.

4- In November 2001, he presented his vision on the issue of the accessibility of pharmaceuticals as one of the main topics discussed during the World Health Organization, Executive Board Retreat in Florence, Italy

· He was elected Chairman of the Board of Partners in Population and Development in November 1998. This organization utilized a South-to-South approach as well as North to South Cooperation. It included 14 countries, which shared and exchanged information and experiences.

Those who have followed the accomplishments of Ismail Sallam are curious whether his guidance and vision can lead and reform the WHO. The growing disparity in health care services around the world require both the leadership and commitment of a figure with clear objectives. Sallam has a special cocktail that has succeeded in the past to miraculously reform and modernize health care services in the areas under his auspices. He has been successful in transferring the onus from the health of an individual alone to that of the family and community. He has also emphasized during his tenure the importance of collaboration in health care services by recognizing the fundamental role of a TEAM (Together Everyone Achieves More). With this vision, he has built training workshops for all health care providers in every community in Egypt. These included the doctors, nurses, social worker, psychologists, pharmacists, computer technicians, and administrators.

Sallam's cocktail concentrates on both the curative and preventative sides of health care particularly of infectious diseases. One disease that plagued Egypt for millennia is schistosomiasis. Under his leadership, the incidence of the disease has dropped to 3% and Egypt is preparing celebrations in the year 2005 to commemorate the end of the disease in Egypt. Similarly, the incidence of polio has nearly vanished. He recalls the support and effort done by Egypt's first lady Suzanne Mubarak to push for these awareness campaigns.

The success of Sallam's cocktail is built on bringing together 3 medical systems: the National Health Service, free Governmental medical services, and the private health care system. Sallam has concentrated on creating both harmony and cooperation between these systems to provide the best services possible. The cocktail also includes a participatory dimension that emphasized community involvement in the health care system to help reform it and take health education to the people that need it most.

Sallam's cocktail also pushed for scientific exchange between Egypt and its Arab, African, and Asian medical counterparts. Cooperation between the international medical associations both in the emerging and developed countries has helped improve health care service across the board. Many international figures have been invited to help modernize the health care system in Egypt. Likewise, thousands of Egyptians visited international centers to be trained on the latest developments.

Sallam has also been a critical spokesperson and decision-maker. During the united Nations International Conference on Population and Develoment (ICPD) held in Cairo in September 1994, CNN broadcast a clip of a female circumcision (FGM) in Egypt. This created an uproar about the issue and bought it to the forefront of debate in Egypt with the public taking side both for and against it. Some argued it was an Ancient Egyptian tradition, calling it Pharaonic circumcision. At such a critical time, strong leadership was imperative to deal with this sensitive issue. Sallam was that leader, announcing without hesitation the prohibition of the practice in Egypt..

As an avid follower of health care issues in the emerging world, I have been highly impressed with Sallam's accomplishments and contributions and reviewing both the credentials and portfolios of the other distinguished nominees. My father's letter to the Lancet also gauged my interest since he has know Prof. Sallam for four decades. When I inquired about his expectations on the January 28 vote at the WHO, he said that "Prof. Sallam was an ideal student, an ideal doctor, and ideal professor, an ideal humanitarian, and an ideal minister. I'm sure he would be an ideal reformer and modernizer for the WHO in the 21st century."

"I am a man who dedicated my life researching Egyptian history and archeology. I was the one who discovered many aspects in the progress of health during the old ancient Egyptian history, which was remarkable. In the last few years, I have witnessed a remarkable change in Egypt's health sector achieved by Dr. Ismail Sallam, who led a profound health reform policy in Egypt. He was able to make Health for All a reality for all Egyptians.

He had a different approach in an attempt to reduce poverty in Egypt through addressing effective interventions needed in health field including equitable and accessible health services for the poor and the marginalized groups.

With great capabilities, Dr. Sallam, in short time, restructured health strategies and priorities and enhanced the efficiency, transparency, and accountability of health in Egypt. That was really a great challenge under the pressure of population and limited resources.

He relied in the first place on human resources development where he could succeed in creating an exceptional generation that was trained and motivated to build up enthusiastically this unexpected achievement.

Evidently, Dr. Sallam could foster partnership among government, academia, non governmental organizations, and the private sector to promote linkage in support of the health system.

Equity in providing health services went beyond primary health care to include specialist services, but more importantly, he is the founder of the new economic basis for the utilization of the available resources by maximizing efficiency without increasing budgetary allocations. The system added more independence to the public hospitals with the introduction of private practice within the public premises in a successful attempt to enhance accessibility with quality to the unprivileged groups.

There is much to be said about our hopes for the unprivileged groups all over the world and I feel that the WHO should have a new insight and tactics for achieving such goals."

"Dear Sir, I read with great interest all the articles published in the debate about the upcoming WHO Director-General elections. I am honored to know one of the candidates personally. Prof. Ismail Sallam, the distinguished cardiac surgeon who succeeded in modernizing medical services in Egypt during his 6 year term as Minister of Health and Population. His interest in establishing strong cooperation between the North and South in biomedical fields helped him build a solid base of specialists in all medical fields in his country. Last year, Prof. Sallam established the first the community genetic clinics in public hospitals, which were distributed equally throughout Upper and Lower Egypt. I was honored to join a leading Egyptian team to help in the implementation of this model and in training of family doctors, nurses, social workers and psychologists.

Prof. Talaat I. Farag, MD, FRCP(Edin), FACP, FACMG
Community Geneticist & Syndromologist
Adjunct Professor, Dalhousie University, Canada
e-mail:tfarag@dal.ca

"We became highly interested in the debate regarding the upcoming WHO Directo-General elections through your published letters on the distinguished candidates. As family physicians, we feel that the 21st century needs a reformer and moderniser of global health care systems. The model has to fulfil the needs of more than six billion people of different ethno-cultural backgrounds, gender and religion.

The supporting letters for Ismail Sallam published by H. El-Sayed and T.I.Farag showed that how he respects the importance of primary health care and the role of family physicians to control communicable and non-communicable diseases. It also showed that the Egyptian experience in the implementation of community genetics services and his interest in strengthening the cooperation between the North and South in biomedical fields is promising and recommended.

We support Ismail Sallam's nomination for the WHO Director-General position, since he seems to have a clear and effective health care agenda."

Hany Milio, MD & Gehan Ghally, MD
Family physicians
Waterloo, ON, Canada
e-mail:hmilio@rogers.com

"I read with interest your Sept 14 Editorial, as well as the Special Report on Oct 12. I must first of all congratulate you for highlighting this issue.

You rightly indicated that the overwhelming impression of the organization is one of a top-heavy, slow moving, overpoliticised, and even corrupt body. Accordingly the election of such a leading position at this juncture requires both attention and the exposure.

Having read the list of possible candidates, I am particularly pleased to see that Prof. Ismail Sallam, the former minister for health in Egypt is included. We have had the pleasure of working and co-operating with him over the last number of years in the areas of pharmaceutical education and training for health care professionals in Egypt as well as auditing prescribing for the national health insurance program.

This co-operation has led to the signing of a special memorandum of understanding and co-operation by the Irish Minister for Health and Prof Sallam's department in Cairo last year.

He is a prominent cardiac surgeon and a very respected academic; he is also a master of the art of politics. He uses his charm and charisma and his power of persuasion to achieve his aims. He has great organizational skills which he needed in order to run a complicated ministry in Egypt at a time of budget shortages and an ever-increasing population.

One only hopes that the election of the incoming director-general will not be just a political issue and the most suitable candidate is appointed in order for the organization to regain its respectability and to continue the reforms that Brundtland started."

Prof Kamal Sabra
Faculty of Health Sciences,
Trinity College, Dublin, Ireland
E-mail:ksabra@stjames.ie

"Over the past decade or so, Dr Sallam has had a tremendously influential contribution to healthcare services in his home country of Egypt and beyond. As a mass media scholar with a particular interest in public health and communication/awareness campaigns, I have witnessed Dr. Sallam's monumental contribution in this area. His dedication, leadership, and commitment to healthcare development particularly in developing countries has created an infrastructure for improved facilities and services in areas he administered during his eventful tenure as Egypt's Minister of Health and Population. It is certain that Dr. Sallam's background in Africa and the Middle East will place him in the position to enhance healthcare provisions in the regions most in need of both political and service reform. As Director-General of the WHO, I am certain that Dr. Sallam, as he has done in the past, would be capable of rallying international support for the most pressing of issues. His portfolio and personal experience speak volumes about his skills both as an administrator and an organizational leader. For this reason, I lend my undivided support to Dr. Sallam for this prestigious and vital position."

Adel Iskandar
University of Kentucky
Lexington, KY, USA
E-mail:adel_iskandar@hotmail.com

"The result of successive Egypt Demographic and Health Surveys indicates that the use of family planning methods increased in Egypt from 24 % in 1980 to 48% in 1995, then to 56 % in 2000 despite the rapid increase in family planning use. The discontinuation rate and unmet need proportion is still high. In order to reach women with unmet need and to deliver quality family planning services, the Minister of Health and Population Prof. Dr. I A Sallam adopted an extensive mobile clinics program in 1997. The overall objectives of the mobile clinics are to provide health services in the deprived areas and to serve poor people by providing services free of charge.

The mobile clinics are targeting the deprived areas and poor people. The definition of these categories of areas and people includes all areas with no Ministry of Health and Population (MOHP) health facilities. Examples of these areas include deprived villages in rural areas and squatters in urban areas. These areas are determined by health directors, the family planning directors, and the local community leaders.

With total number 320 mobile clinics for women's health, mobile clinics cover almost all the deprived areas defined by MOHP.

The monthly average number of family planning clients increased from around 17 clients in June to 130 in December, 1999. This result indicates the continuity in the increase of the demand for family planning services provided by mobile clinics and also explains the decline in the percentage of unmet need from 16% in 1995 to 11.2% in 2000 (DHS), since these mobile clinics attract a new, previously unreached group of women. The mobile clinics distribute higher quantities of family planning methods than fixed clinics. In 1998 and 1999, the mobile clinics distributed on average around double the quantities of various contraceptives distributed by fixed clinics.

The providers in mobile clinics use a gentle and kind voice, listen attentively, maintain eye contact, and use a language level that the client can understand in 97% or more of cases. This happens in fixed clinics in around 80% of cases.

There are 320 mobile clinics for reproductive health, 30 dentistry clinics, 40 clinics for internal medicine and minor surgery; these different types of mobile clinics serve to attract the target groups by comprehensive medical services."

Essam Farag BA Honors (Dal) is a graduate student and teaching assistant in the Department of Political Science, Guelph University, Ontario, Canada. He is the former president of the Dalhousie Arabic Society (DALAS).