Lambasted over Covid-19, slow in its response to Ebola, and led by a man who once appointed Robert Mugabe as goodwill ambassador, the World Health Organisation (WHO) is under fire. President Trump has announced he will suspend US contributions, the largest single slice of its funding. But its many detractors offer no workable alternative. Without international co-operation, Covid-19 will not be beaten. Nor will a plausible exit strategy—or any return to sustainable economic growth—be possible.
The WHO as we know it today took 170 years to build. Way back in 1851, countries started trying to find a way to co-operate in the face of infectious diseases, such as cholera and plague. During long sessions of International Sanitary Conferences, before and after the First World War, international rules were carefully worked out. But at every stage, co-operation was thwarted by disagreements among technical experts, by the costs of preventive measures, and by the short-sighted selfishness of many national governments.
The efforts at health diplomacy culminated in the creation of a new standing transnational body in 1948, with the WHO’s work beginning in earnest three years later—exactly a century on from that first international conference. It was born in that rare moment of enlightened multilateralism that followed the Second World War, which also saw the creation of the United Nations, the International Monetary Fund and the Council of Europe.
The temper of our own times is very different, but the basic rationale for close co-operation on public health is still rock solid. Without it, the spread of Covid-19 will take longer to detect, trace and contain, those afflicted will suffer untreated for longer, and—crucially—it may never be possible to draw a robust line under the disease.
So how do we ensure that co-operation? For starters, it requires an international agency trusted to bring together the scientific evidence and to ensure the sharing of information among governments—the very job for which the WHO was created. But today, it is caught in the crossfire of a blame game. It is criticised for having cosied up to China, and for wasting precious time. (See not only Trump, who is never slow to hunt noisily for a scapegoat, but also Japan’s deputy prime minister, strategic studies expert Lawrence Freedman, Bloomberg and the Atlantic.)
There is no denying the WHO has had a few uncomfortable moments, such as the painful TV interview where, when pressed to praise Taiwan—thereby potentially annoying China, which doesn’t recognise the country—assistant director-general Bruce Aylward first claimed he couldn’t hear the question, and then urged the interviewer to move on.
But far from a blame game, what this crisis requires is careful attention to what needs to be done. And several basic things are missing in the angry outbursts at the WHO, starting with an appreciation of the inescapably inter-governmental character of the body. As it makes difficult calls to balance prudence and speed in the deployment of stretched resources, it cannot afford to pick avoidable fights with any of its members. Its tricky job is to get (sometimes mutually hostile) governments to work together to save lives. And the precondition to doing that is to navigate the other political tensions with the requisite diplomacy.
Foundation of trust The WHO simply has to be trusted by governments to be effective. If a government hides information or refuses to take its advice, the WHO cannot send in an enforcement army. “Cosiness” with its member governments is not an optional indulgence, but hard-wired into the structure.
Consider why a government would notify the WHO of any outbreak of disease in the first place, knowing it could face costly and immediate cut-off from other countries, affecting travel and trade. This is why the WHO promises to oppose knee-jerk travel and trade restrictions against a country reporting disease, something it has been attacked for in the coronavirus context. But to do otherwise would be to encourage countries not to report, choking off the stream of information on which all hopes of a rational, cross-border approach to public health depend.
Things could have been far worse if China had regarded the WHO as hostile. As it was, Beijing first reported a cluster of cases of pneumonia in Wuhan on 31st December 2019. (Incidentally, and inconveniently for those who want to blame the coronavirus crisis on a WHO/Beijing stitch-up against the world, the Chinese government has since disciplined local officials for hiding the scale of infection prior to this.) The WHO was then quick to act. The next day, on 1st January 2020, as the head of China’s centre for disease control briefed his counterpart in the United States, the WHO set up an Incident Management Support Team, putting its organisation on emergency footing.
After the initial reporting is out of the way, the WHO also needs the trust of governments so that countries share virus information. In February 2007, the world saw what happens when that trust wasn’t there. During an international outbreak of swine flu, Indonesia stopped sharing H5N1 samples with the WHO, claiming—incorrectly—that the organisation was passing them on to pharmaceutical companies to make vaccines for which Indonesia would then have to pay very high prices. Without such samples, the WHO was hamstrung in what it could do for the immediately affected country—and the world beyond.
[su_pullquote align="right"]"In the UK and US weeks went by without the adequate development and rollout of testing"[/su_pullquote]
By contrast, in the current crisis, on 9th January the Chinese health authorities and the WHO announced the discovery of a novel coronavirus, known as 2019-nCoV, and over the weekend of 11th-12th January, the Chinese authorities shared the full sequence of the coronavirus genome. Consequently, by 16th January German researchers in Berlin had already developed a new lab test for the virus, soon followed by companies in South Korea. In both nations, preparations for rolling out large-scale testing for the virus began immediately, permitting these countries to follow WHO advice which was to prioritise testing in order to “intensify case finding, contact tracing, monitoring, quarantine of contact, and isolation of cases.”Other countries did not follow the WHO advice, and there was little the organisation could do. In the UK and the US, weeks went by without the adequate development and rollout of testing. Both were forced to limit testing severely as the virus spread. In the US, by 12th February the Centres for Disease Control and Prevention had to admit that its tests were not only inadequate in supply but defective. Even in late March, Public Health England was struggling to deliver enough tests, leaving thousands of health workers untested.
If the WHO were in the business of criticising governments it would have no shortage of governments to choose from. But it would not enhance global co-operation by playing “critic-in-chief.” It can only function by understanding its role, which is to be entrusted by governments with the role of “adviser-in-chief”—a status that necessarily constrains the way it works.
Alarming business Critics argue that the WHO was too slow to sound the full alarm bell on coronavirus. But the bitter experience of the WHO highlights how fraught that call can be. In 2010, the organisation was castigated for labelling swine flu a pandemic. That virus turned out not to be as dangerous as it feared. Five years later it was much more careful when Ebola broke out, and this time it was pilloried for not calling an international emergency faster.
As we are witnessing with the Sars-CoV2 virus, scientists do not quickly form a consensus on the epidemiology or likely trajectory of a virus. Debates are now raging about whether Covid-19 will die out or mutate into a more (or less) lethal form, about whether human beings will develop immunity to it, and if so, for how long.
Even where a sufficient weight of expertise settles into a consensus, the WHO is not automatically free to act on it. It cannot declare a “Public Health Emergency of International Concern” (PHEIC) without convening an Emergency Committee of experts to review the evidence and make a call, a restriction governments have imposed. The WHO convened such a committee on 22nd-23rd January and it failed to reach a consensus. Fortunately, it did not let matters rest. Instead, it despatched a senior delegation to China to gather more data and to call a second meeting of the Emergency Committee at which the experts gave approval to declare a PHEIC on 30th January.
The declaration of a PHEIC signals to the world that there is an ongoing epidemic or disease outbreak that is a serious risk to several countries, demanding a concerted response. It gives the WHO a mandate to act. The next step is for the WHO to escalate and declare a pandemic—which triggers direct action by individual governments. For an organisation that relies on goodwill and contributions from its members to be able to do anything effective, this can be a fraught call. If it calls a pandemic too early, it can lead to countries automatically triggering their pandemic preparedness plans. If the WHO turns out to have been wrong, governments may have committed to unnecessary expenditure. Worse, if there is a rushed recourse to off-the-shelf plans, they may not be appropriate to the specific virus, and especially where that virus is new, as with Sars-CoV2.
Adviser-in-chief It was not until 12th March 2020 that the WHO declared a pandemic. The organisation explained in late February that its experts were not then witnessing the uncontained global spread of the virus or mass casualties, but it was careful to register that countries should prepare for this to change. Indeed, the head of the WHO’s health emergencies programme clearly warned countries to “do everything you would do to prepare for a pandemic.”
Here the WHO is in a bind. As adviser-in-chief the WHO must be prepared to warn of things, and to prepare for things that may not happen. During the 2014 Ebola outbreak, the organisation was excoriated not only for its slowness to declare a pandemic but for its limited “surge capacity,” its lack of clear operational response, its failure to work effectively with other partners, and its failure to directly and urgently communicate about the outbreak. Later the leadership of the WHO accepted that it needed to do better.
In this crisis, it has communicated faster and more effectively. Starting on 4th January, the WHO reported on social media that there was a cluster of pneumonia cases in Wuhan and on 5th January published its first Disease Outbreak News on the new virus. Technical guidance for all countries on how to detect, test and manage potential cases followed on 10th January and has been updated ever since. So the will to do the right thing was demonstrably there, but—sadly—good intentions are not always enough.
The WHO’s total budget is about that of one large American hospital. The money is contributed by governments, and agreed biennially—the total over 2020 and 2021 is $5.8bn.
[su_pullquote align="right"]"In the WHO alienated multiple major members at once it's existence would soon be at risk"[/su_pullquote]
Worse, only 17 per cent of that inadequate budget—just $960m—is the assessed contributions upon which the organisation can rely for funding its core operations. The remaining 83 per cent constitutes “voluntary” contributions that are mostly tagged for special purposes. Further eroding the core budget is the fact that part of it then has to be spent subsidising the overheads on these voluntary-contribution funded projects.Through such means, governments who wish to take forward essentially bilateral initiatives can channel them through the WHO, and acquire the virtuous look of being funders of genuine international co-operation—a phenomenon that Devi Sridhar and I have described as “trojan multilateralism.” It may or may not be good PR for governments, but the effect on the WHO is to starve it of that core capacity which it needs to respond effectively to a pandemic.
In the aftermath of Ebola, an independent panel proposed that the WHO should ask governments to increase their assessed contributions by five per cent. Margaret Chan, the then Director-General, attempted this and failed. Governments instead opted to continue a longstanding freeze on contributions in cash terms, with no allowance for inflation. The result is an even weaker financial core than five years ago.
Jigsaw governance And while money is tight, layered governance complicates the question of who gets to call the shots. As well as its headquarters in Geneva, the WHO has offices in many countries, and an additional intermediate layer of regional organisations with operational autonomy based in Brazzaville (AFRO), Copenhagen (EURO), New Delhi (SEARO), Cairo (EMRO), Manila (WPRO), and Washington DC (AMRO). The complex organogram grows out of the need for effective global reach, but it still makes executive decision-making that bit more difficult.
The Director-General must exercise leadership in three domains: forging agreement among governments to act together; persuading them to fund the organisation; and managing the organisation itself (staff and culture) to achieve good results.
Dr Tedros Adhanom Ghebreyesus was appointed in 2017. He had previously served as Minister of Health in Ethiopia. Early in his tenure as Director-General, he made the one misstep I referred to—appointing Robert Mugabe as a Goodwill Ambassador on non-contagious diseases. Crucially, however, he realised his mistake. In the words of Richard Horton, the editor of the Lancet, he reversed himself in “a spectacularly courageous fashion” and rescinded the appointment.
Dr Tedros is now trying to lead diverse and competing governments in a collective and unprecedented fight against a pandemic. Those same governments, before the pandemic, refused to delegate more authority to the Director-General or to ensure his organisation is properly funded. If you want to understand why it treads carefully with major members such as China, it is only necessary to consider the capricious treatment it has received at the hands of Trump. If the organisation alienated multiple major members at once, then its effectiveness would be shredded, and—if contributions stopped—its existence would soon be at risk.
And what a needless tragedy that would be. As Dr Tedros said on 9th February, “the virus is a common enemy,” adding “let’s not play politics here.” He was right. Each country could take its own decision about locking down, but a sustainable exit strategy will require co-operation among them to ensure testing, treatment and above all vaccine research, production and dissemination across the world. Even when a vaccine is available, it will never reach all corners of the world without international co-operation. It is not just the poor countries that will suffer without that global reach—every country will keep risking reinfection. (The rich nations got rid of smallpox within their own borders in the 1940s, but they couldn’t be secure against it returning until the truly global drive for eradication—with the help of the WHO.)
The WHO faces powerful headwinds as politicians try to blame it, even as they turned away from its advice. But public health should be a “no brainer” for inter-governmental co-operation. Viruses know no borders.
