The Limits of the World Health Organization
President Trump has characteristically tried to divert public attention from his botched response to the coronavirus pandemic by blaming others—Democrats, governors, the Centers for Disease Control and Prevention, China. But in the World Health Organization (WHO), he has found the ideal piñata.
The WHO combines all the elements of the populist bestiary—an international organization, staffed mostly by foreigners, whose authority rests on the technical expertise of an elite cadre of specialists. And by portraying the WHO as a puppet of China, Trump has cast the organization as a threat to American security. But the impulse to dismiss Trump’s attacks as narrowly political is a mistake. The WHO is such an appealing target for reasons that go beyond Trump. It’s a casualty of our unraveling international system and was on life support even before Trump was elected.
From the standpoint of most strands of international relations theory—which since the 1990s has become increasingly abstract, idealistic and detached from political realities—the WHO is the embodiment of what international cooperation should be able to accomplish. Having given up dreams of a global government, theorists saw in international institutions like the WHO a way to solve global collective action problems. International institutions offered a middle way between the one-world idealism of the past and the grim prognoses of realist thinkers, who often seemed to think that any kind of international cooperation was impossible.
Indeed, at first blush, the WHO seems like the perfect international bulwark against fast-spreading disease. The mutation of a virus or bacterium in a remote area of one country can quickly flower into a contagion and spread across borders. Many countries are poor and ill equipped to stop the disease before it spreads. And all countries benefit from an early warning system that allows them to shut down borders if necessary, or take other precautions. It seems obvious that it is in the collective interest of countries to fund and support an international organization that serves as a repository of expertise on infectious diseases and stands ready to coordinate an international response when an outbreak occurs.
Moreover, the work of the WHO is inherently technical; it does not need to make the sort of charged political decisions demanded of the U.N. Security Council, where the vital interests of different countries repeatedly conflict. Nor is it required to take a stance on the sensitive ideological values of different countries, as human rights organizations must. And because the WHO’s mission is narrowly defined in relatively objective terms, its performance can be evaluated with relative ease—for example, by using straightforward public health metrics. This ought to give WHO officials incentives to act appropriately and reduce the risk that countries are unable to discipline it if it fails to. The WHO’s leadership in the eradication of smallpox and in advances against polio seemed to validate this theory.
So what happened this time? The WHO blundered early on during the coronavirus crisis by parroting China’s talking points—first that the coronavirus was not a serious threat, and then that China had quickly brought the pandemic under control. The WHO relied on information from China in part because it did not have independent access to data being collected by Chinese doctors, scientists and government officials, and in part because it did not want to offend China. The WHO cannot afford to offend China or any major country because it relies on cooperation from countries—cooperation among decision-makers at the time of medical emergencies, and cooperation in the form of funding and political support. But this means the WHO can be manipulated, as indeed it was at the start of the coronavirus outbreak.
Theory says that countries where disease outbreaks strike should welcome international expertise. The reality is that they do not, at least not in the early stages of the outbreak. They fear that if word leaks out they will lose tourism and business. So they try to handle the pandemic on their own and ask for help only after they lose control. But the WHO can help best, and serve its function, only if it acts as quickly as possible. This paradox hampers the WHO and explains its stumbles in China—and earlier stumbles, including its slow response to the Ebola outbreak in West Africa in 2014.
It is tempting to blame the WHO itself for its problems—its notoriously complex bureaucracy, its decentralized structure, its “culture” or the persons who run it. But all of those things are a result of the political constraints it operates under, as many reform-minded critics have observed. Big bureaucracies are established to guard against errors. In this context, this means staying away from actions that will offend member states whose support (financial or otherwise) is necessary for WHO’s operations. The sorts of bureaucratic reform that WHO insiders and sympathetic critics have called for over many decades would not protect the WHO from leaders like Trump.
It turns out that even the expert-led technical interventions of the WHO are politically charged. And this is not just because some countries want to hide disease outbreaks from the world. Countries also disagree about the problems that the WHO should focus on in the first place. The setting of priorities and allocation of resources among different public-health challenges are policy choices, not technical choices. The WHO is not an anti-pandemic organization or an infectious-disease organization: It is a health organization, and health policy is intensely contested around the world.
Many of the familiar cleavages in international politics had begun to pull apart the WHO long before the coronavirus pandemic. People disagreed about which health threats should be given priority, and the WHO found itself torn between governments, interest groups, activists and donors who wanted the organization to give priority to different things—HIV/AIDS and other infectious diseases, tobacco use, obesity, even climate change. And then there is intense disagreement about whether the WHO should give priority to developing countries and, if so, how much. The WHO has set itself the goal of correcting global health care inequality, which begins to seem like a redistributive program from north to south—the sort of thing applauded by academics and commentators but politically explosive, to say the least.
To address these conflicts, the WHO has put itself on two tracks: retaining relative autonomy to set its own agenda using mandatory U.N. contributions, and otherwise accepting voluntary donations from countries and institutions and yielding to their priorities. But this strategy contributed to problems of focus, leadership and organization—and, in any event, it hasn’t worked. Donors unsatisfied with the WHO’s priorities have set up their own competing global health institutions that pursue agendas different from the WHO’s. These institutions include (and I am paraphrasing a list from a Chatham House report from 2014) the World Bank; the Joint United Nations Programme on HIV and AIDS (UNAIDS); the International AIDS Vaccine Initiative; the Global Alliance for Vaccines and Immunisation (now the GAVI Alliance); the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Medicines for Malaria Venture; the Gates Foundation; and the U.S. President’s Emergency Plan for AIDS Relief. The author of the Chatham House report observes that the proliferation of health organizations has “challenged the WHO’s role as a directing and coordinating authority.”
Inevitably, the ideal of a single institution that engages in “global governance” of the world’s health problems has fallen by the wayside. “Health governance” has fragmented as a result of the proliferation of global health institutions, just as “international justice” is being pursued by dozens of independent national and international judicial systems rather than (in the old dream) a single hierarchical system based on national models.
Commentators believe that the only solution to the WHO’s problem is greater autonomy. As a pair of authors argued in 2014, “the challenge in the twenty-first century will require an even greater willingness to delegate authority and resources to a supranational entity. The time might be ripe for such a bold move.” The time wasn’t ripe then, and it’s even less ripe now. Greater autonomy is impossible; if it could actually be accomplished, the WHO would be even more vulnerable to populist backlashes, like the one being led by Trump right now. The world is moving in the opposite direction—toward fragmentation, and tighter control of international law and institutions by the most powerful countries.
The WHO can endure and serve a useful function but only if it has less autonomy and a narrower mission, with its reins firmly in the hands of the most powerful countries. And an organization committed only to the collection and dissemination of information about infectious diseases and how to control them may well be found tolerable by powerful countries. The WHO’s role in eliminating smallpox should not be downplayed. But whether the WHO can play a positive role in an unfolding crisis where national sensitivities are at stake remains to be seen.