Expert Speak Health Express
Published on Jun 16, 2020
A WHO fit for the 21st Century

On 22 May, Dr. Harsh Vardhan, India’s Union Minister of Health and Family Welfare was elected as Chair of the Executive Board of the World Health Organization (WHO).  The Executive Board is the link between the WHO’s 194 member states and the WHO Secretariat — all the technical and administrative staff of the organization. Vardhan’s one-year tenure from now until 21 May 2021 will likely be one of the most pivotal years in the organization’s history and of the world. While India’s aspirations to become a major global power through economic and military prowess have become hobbled by the COVID-19 pandemic, it may still have some potential to do so in the unlikely and long-neglected domain of global health diplomacy.

Vardhan’s tenure begins right when President Trump ‘terminated’ the US relationship with the WHO with the intention to undermine it, when so much of its work has helped developing countries. It is also a direct attack on WHO’s relatively new mandate to act as a coordinating agency during an international health emergency.  The US pulling out of the WHO has shocked and outraged many people worldwide.  But, it really should not. Such a move is made possible because of a widely shared American view that the US is a major benefactor to a global health charity, as opposed to being a member of an essential global institution that helps protect American and global health. The move also reflects enormously bad ethics.  Even a benefactor has some moral duties to cease involvement and funding only after a plan is put in place when human lives are at stake — especially during a pandemic which has killed hundreds of thousands around the world.

"Even a benefactor has some moral duties to cease involvement and funding only after a plan is put in place when human lives are at stake — especially during a pandemic which has killed hundreds of thousands around the world."

However, the loss of US funding to the WHO is both an unthinkable reality as well as a once in a lifetime opportunity to put the organization on track to make it fit for the 21st century. In addition to becoming heavily reliant on the US government and the Gates Foundation for most of its budget, the WHO and global health have long been dominated by American national interests, ideas and values at the exclusion of others. For example, the political lightning rod issue of access to healthcare in the US has been evolving over decades. And it profoundly influences how American government officials, academics and others understand and contribute towards the Universal Health Coverage (UHC) agenda put forward in the Sustainable Development Goals (SDGs). Initially, UHC was not just about healthcare coverage, it was about building the most impactful determinants of good health. It is now confined to healthcare partly because of the American perspective that sees health as being about healthcare; it’s health economics paradigm; vast numbers of healthcare management consultants; and it’s national interest in promoting business interests in healthcare world-wide. There are no comparable American business interests in building good conditions for health, i.e., public health. I would be probably working at one now, if there were.

"Initially, UHC was not just about healthcare coverage, it was about building the most impactful determinants of good health. It is now confined to healthcare partly because of the American perspective that sees health as being about healthcare."

The influence of the US government on the WHO and the broader global health agenda since the 1990s has been phenomenal. And the influence of American funders, especially the Gates Foundation, programme implementing organizations, academics, and all others combined put American influence leagues ahead of any other country. Some Americans, and others, would argue that the influence has gone too far. China’s recent and massive efforts to build or finance healthcare infrastructure in many low income countries follows the US tradition of using health aid to pursue national interests, and actively seeking to check it. And whatever conversations may have occurred between WHO and Chinese officials regarding the outbreak in Wuhan, America was in the room.

At the same time, pulling out of the WHO mistakenly attributes it more influence than it actually has. The WHO’s influence on all governments including China is largely the power of persuasion. It does not have any sticks or sanctions in its toolbox, nor are there any binding obligations on governments — including the reporting of outbreaks to the WHO. This is despite there being a formal agreement on reporting in the 2005 International Health Regulations (IHR). The IHR could have been different. The non-binding or voluntary nature of reporting outbreaks to the WHO was put in place by the same countries who agreed to sign the IHR. No country wanted to give up its sovereign right to determine how and when it reported an outbreak. This included the US, which is a party to the IHR and — as always — a dominant voice in the drafting and subsequent revising.

The result has been that while the WHO can plead, cajole, and even grandstand, WHO officials cannot force any country to report. This is why attacks on particular individuals working for the WHO, including the Director General, are pernicious and misguided. They are servants of the parties that drafted the rules, and must make their best efforts within those rules to elicit information from one member state in order to assess the situation, and advise other member states. To put it another way, in a dysfunctional family, abusing the household servants may be commonplace, but it is a losing game for all. I am using the metaphor of a servant purposefully here, as it can help understand the perspective of a person and a nation who usually see themselves as major benefactors of charities.

"While the WHO can plead, cajole, and even grandstand, WHO officials cannot force any country to report. This is why attacks on particular individuals working for the WHO, including the Director General, are pernicious and misguided."

In any case, the WHO Secretariat has limited tools to persuade governments.  Between a carrot and stick — which it does not really have — WHO officials chose the carrot approach in hopes that the Chinese government will act as a responsible global citizen and be forthcoming with information. The reality that needs to be recognized is that many other countries, including the US or India, would have also acted similarly for the sake of buying time while planning how to protect their national and commercial interests.

With regard to outbreaks, if governments want the WHO to be more effective then they must give some teeth to the IHR. This means agreeing to hold other countries and themselves more accountable for failures to report. It would mean promoting mutual solidarity and protection of global health over national interest. As has been evidenced in this pandemic, governments prioritizing national interests and unmitigated sovereignty above mutual cooperation fail in the duty of care of their own citizens. It also denies showing minimal respect for other human beings in other countries. And, in retrospect, a bit more enforcement power in the IHR would have been less costly than the trillions of dollars countries are spending now and decades of austerity. The US pulling out of the WHO does not solve this problem intrinsic to the IHR, and more generally of the governance structure of the WHO. It is a problem that needs to be solved as there will be more outbreaks. And the COVID-19 pandemic, despite its devastation, is not the really harmful pandemic that many experts were expecting. This present devastation is being caused by bad governance and bad ethics as much as by the virus. The open question is will the IHR be revised in light of the pandemic, and will it be done with or without the US involvement?

Furthermore, “America first” is not an agenda that is unique to this current President and administration. It has been the agenda of every previous US administration, and is a constitutional duty of every American President and government official. So, ironically, pulling out of the WHO means the US is gagging itself from speaking inside the WHO, and is undermining the duty of putting America first. Indeed, American influence on the WHO has not always been good for global health or for the health of the worst off in the world. It actively resists WHO work that might hurt American company profits (tobacco, alcohol, sugar, technology, etc.), and it hinders the work on reproductive and sexual health, among other issues.

"Pulling out of the WHO means the US is gagging itself from speaking inside the WHO, and is undermining the duty of putting America first. Indeed, American influence on the WHO has not always been good for global health or for the health of the worst off in the world."

But there are also profoundly good American influences. Americans have historically been involved in — and often at the forefront — of containing infectious disease outbreaks. They have helped create new ways to measure the burden of disease and impairments. There are Americans who single-handedly take on neglected health issues, drawing on the intellectual, financial and human resources in the US. And elite US universities provide training for so many individuals who currently work at the WHO headquarters and regional offices. Even most of the interns are American, who actually do a lot of work.

The end of the WHO-US relationship, hopefully brief, means a huge loss of income for the WHO. But the reason it has become so reliant on the US government and Gates funding is partly because other countries are not paying what they should. Member states are paying dues based on calculations from decades ago. For the WHO to be fit for the 21st century, assessed dues must be based on what countries can afford today, and should be periodically updated in the future. Because member states are not jointly willing to increase all of their contributions, more than 80% of the WHO budget is made up of additional voluntary contributions. This also means funds are allocated to the funder’s priorities. The loss of US money means the immediate loss of staff and possible end of work on some important health issues.

But, as I teach my students and tell audiences worldwide, money is not the primary problem in global health or at the WHO. It is the lack of good reasoning, ideas and ethical values. There is plenty of money in the world with governments. Trillions of dollars appeared overnight to bailout banks and economies in 2008. Even more trillions have been marshalled over the last two months. The clear challenge right now for the WHO and its advocates is to make the case to potential donors for replacing US funding. But it is also an incredible opportunity for governments and citizens to take more ownership of the WHO and get rid of structural drags in its ability to function robustly, transparently and fairly. Because there is so much money in the world, there will be quick ways to shore up WHO funding while continuing the ‘pay to play’ game so familiar in American politics. Or, the organization can move towards becoming a model global institution where the benefits and burdens are distributed fairly across member states and their citizens, based on mutual interdependence and collective action. It will be a much better and stronger organization when the US eventually returns. And it will.

In the meantime, will India and Minister Vardhan try to quietly move through the year, hoping to escape the attention of the current US President while containing China, or bring more fairness to the WHO and the world order?

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