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  • Christoph Gradmann is historian and professor for the history of medicine at the University of Oslo.

  • Jean-Paul Gaudillière is historian and senior researcher at the French state research institute Inserm and professor at the École des Hautes Études en Sciences Sociales in Paris.

On April 15, Donald Trump announced the suspen­sion of the United States‘ contri­bu­tion to the WHO budget pending an inves­ti­ga­tion by the United States government into the organization’s atti­tude towards China. In a Tweet version, the message was blunt: if the WHO had not covered up China’s silences and denials, the Trump admi­nis­tra­tion would not be facing a double health and economic disaster and a major leadership crisis. Most Euro­pean commen­ta­tors have taken this episode for what it is: the search for a scape­goat and the conti­nua­tion of a long-term offen­sive against the inter­na­tional orga­niz­a­tions and against multi­la­te­ra­lism in general.

While affir­ming their distance, the same Euro­pean media and diplo­matic circles are nevertheless playing another little tune evoking the instru­men­ta­liz­a­tion of the same WHO by China. From the reser­va­tions about trans­mis­sion between humans to the late dispatch of a mission to China and the publi­ca­tion of the first progress report only on 21 January, the sequence of events between the end of December 2019 and the end of January 2020 raises legi­ti­mate ques­tions. For the custo­mary WHO obser­vers, however, this is a far cry from the bankruptcy that followed the Ebola epidemic and which has fed internal criti­cism at the WHO.

Tradi­tions of Displea­sure

What is at stake in the current debate is there­fore on a diffe­rent register than a simple evalua­tion of the measures recom­mended, or not, by the WHO over the past four months. To under­stand what is at stake, it is worth taking a detour through history. Not that compa­rison with past health crises allows one to draw „lessons“ all that easily. However, the WHO’s actions, just like Trump’s, are evol­ving along paths laid out in the history of inter­na­tional public health since World War 2.

Trump plays on a long tradi­tion of American hosti­lity to UN insti­tu­tions. Since its incep­tion, and even when the United States believed that domi­nance of the UN system was essen­tial for the successful manage­ment of the Cold War, it has always regarded the WHO, more than any other UN orga­niz­a­tion, as a bureau­cratic and useless insti­tu­tion. In 1946, citing a satis­fac­tory expe­ri­ence with the Pan American Health Orga­niz­a­tion, the United States argued not for the crea­tion of a UN agency, but for regional coor­di­na­tion and the expan­sion of bila­teral aid programmes. Their support for the inci­pient WHO was reluc­tant and Washington’s inter­na­tional health policy from 1950s to the 1970s favoured the construc­tion of ad hoc alli­ances with UNICEF, WHO, the World Bank and the United Nations Deve­lo­p­ment Programme.

World Health Orga­ni­sa­tion Malaria confe­rence in Lagos, 1955; source: wikimedia.org

Deco­lo­niz­a­tion, the acces­sion of the new nation-states resul­ting from successful strug­gles for inde­pen­dence and the resul­ting trans­for­ma­tions of the WHO by a much expanded membership basis only served to rein­force these reser­va­tions. The demo­cracy of states, which is the norm of a poli­tical body like the World Health Assembly (the highest decision making body of the WHO), requires that the stra­tegic choices and budge­tary invest­ments of the orga­niz­a­tion be decided according to the principle of „one country, one vote“. By contrast, contri­bu­tions to the finan­cing of the insti­tu­tion are made in propor­tion to GDP. By far the largest contri­butor, the United States has always felt that its influ­ence was not commen­surate with its contri­bu­tion.

Worse, in the 1970s, the WHO, under the leadership of the Dane Halfdan Mahler, became the voice of the non-aligned coun­tries, many of which belonged to the “Third World”, with the adop­tion in 1978 of a policy labelled “Health for all by the Year 2000”. Its stra­tegy centred on advan­cing primary health care. The WHO aspired to a major role in calling for a new world economic order and a revi­sion of the terms and targets of deve­lo­p­ment aid. As many of the major programmes desi­gned in the North proved inade­quate and inef­fec­tive because of their opera­tional limi­ta­tions (such as mosquito resis­tance to DDT in the case of malaria programmes), or because of their social unac­cep­ta­bi­lity (as in the case of steri­liz­a­tion poli­cies for birth control), WHO was betting on a medi­cine that was more social than tech­nical.

This approach should be consi­dered a „hori­zontal“ stra­tegy since it involved: (a) clai­ming a right to health in general; (b) linking health inter­ven­tion and deve­lo­p­ment; (c) redu­cing the role of trans­fers of advanced tech­no­logy from the North to favour local resources, afford­able simple solu­tions; and (d) giving prio­rity to rural popu­la­tions, commu­nity health centres and the invol­ve­ment of „commu­nities“. Contrary to the offi­cial WHO slogan, „health for all by the year 2000“, the agenda was driven by a strict prio­ri­tiz­a­tion of the so-called „basic needs“, in this case: the fight against infec­tious dise­ases, and maternal and child health.

A Crisis and a Stra­tegy

The arrival of Ronald Reagan as US Presi­dent in 1981 marked the begin­ning of a full-fledged offen­sive against this stra­tegy, culmi­na­ting in the suspen­sion of the US budget contri­bu­tion in the mid-1980s in reta­lia­tion for the WHO’s support of generic medi­cines produced by and for the coun­tries of the South through the adop­tion of lists of „essen­tial“ medi­cines and the promo­tion of local produ­cers. For the United States, and in this they shared the point of view of big phar­maceu­tical compa­nies, the very notion of „essen­tial“ medi­cines was a problem since it implied putting into perspec­tive, from a public health view­point, the useful­ness of the most recent and most expen­sive patent protected medi­cines.

The episode left deep traces: the United States, supported by some Euro­pean coun­tries, obtained, in exchange for their return to the funding table, an over­haul of the WHO’s gover­nance that now favoured non-budgetary funding mecha­nisms outside the control of the World Health Assembly. The resul­ting infra­st­ruc­ture of „vertical“ programmes targe­ting a single objec­tive (such as immu­niz­a­tion or maternal health), based on a limited register of rather tech­no­lo­gical inter­ven­tions, and steered by the part­ners­hips that fund them, this project-based opera­tion still repres­ents the bulk of the organization’s resources today.

Global Health

It would be simplistic to see in these tensions with the United States the source of all the WHO’s ills and fail­ures. If the primary health care stra­tegy had become incre­a­singly diffi­cult to sustain in the 1980s and 1990s, this was less because of the US offen­sive alone than because of its conjunc­tion with the HIV/AIDS epidemic and in addi­tion with the economic meltdown of low and middle income coun­tries, which were now caught in a spiral of debt crises and struc­tural adjus­t­ment programmes. That lesson stuck ever­y­where: The new players in what came to be called global health, from the Global Alli­ance for the Vacci­na­tion of Infants to the World Bank, the Global Fund to Fight AIDS, Tuber­cu­losis and Malaria and the Bill & Melinda Gates Foun­da­tion, have largely taken on board the criti­cisms of the poor func­tio­ning of the WHO and national health bureau­cra­cies. Making vertical programmes their preferred instru­ment, global health became asso­ciated with government through audit and perfor­mance evalua­tion, ideally defined by cost-effectiveness analyses of health services.

The WHO adapted to this new global health during the direc­tor­ship of Go Harlem Brundt­land from 1998 but attempted to safe­guard some of its previous agenda. Its mandate and struc­ture never became that of an opera­tional agency, but remained that of a repre­sen­ta­tive poli­tical body, sanc­tioned by member states. Indeed, since its crea­tion, its role has been more that of an agency produ­cing exper­tise, serving as a repo­si­tory for agreed stan­dards, regu­la­tions and recom­men­da­tions for the benefit of the Member States than that of a centre orga­ni­sing programmes let alone provi­ding mate­rial and finan­cial resources. Being an essen­ti­ally poli­tical body is a strength when a certain consensus faci­li­tates to converge on inter­ven­tions, as in the case of vacci­na­tion campaigns. It is, however, a great weak­ness when it comes, on the contrary, to influ­en­cing agendas. Where indi­vi­dual states or big NGO can stra­te­gi­cally create agendas, the WHO is easily para­lyzed by disagree­ments between its members. This has been demons­trated over the last twenty years by the inabi­lity to trans­late into opera­tional programmes the huge amount of data and the intense debates on the new epide­mio­lo­gical tran­si­tion known as ‘double burden’, in other words, on the dramatic impact of malnut­ri­tion and chronic dise­ases (from obesity and diabetes to mental patho­lo­gies) in Africa, Asia and Latin America.

Covid-19 and the Geopo­li­tics of Health

Tedros Adhanom Ghebreyesus, Director general of the World Health Orga­niz­a­tion, declares the coro­na­virus outbreak a pandemic, Geneva, March 11, 2020; source: latimes.com

It is there­fore not surpri­sing that the same combi­na­tion of inade­quacy and neces­sity is at the heart of the WHO’s manage­ment of the Covid-19 pandemic. Since the begin­ning of the crisis, the WHO has been the only global health agency that has played an important role. The other players in the field initi­ally remained silent and then, from March onwards, consi­dered, from the Gates Foun­da­tion to the World Bank, that the prio­ri­ties remained the same: Africa as the main risk zone and biotech­no­lo­gical inno­va­tion for therapy and preven­tion as a horizon.

However, the current fight against Covid-19 takes many of the seemingly obvious facts of global health gover­nance as they have evolved over the last genera­tion in reverse: exper­tise concer­ning the responses is no longer only located in Europe and North America, instead if anyone it is East Asian states like South Korea or Taiwan that inspire; stra­te­gies to contain the pandemic rest on the large-scale imple­men­ta­tion of medico-social inter­ven­tions, condi­tioned by the quality of infra­st­ruc­tures (personnel and hospi­tals) which are outside the scope of vertical programmes; finally, inter­ven­tions are based almost exclu­si­vely on the initia­tives of States and their public health admi­nis­tra­tions.

As of the end of January, the tech­nical and poli­tical recom­men­da­tions produced by the WHO have taken note of these three elements. Moreover, by empha­si­zing the „test, trace, isolate“ stra­tegy as the main horizon for perhaps avoiding widespread contain­ment measures, the orga­niz­a­tion demons­trated an auto­nomy from the Chinese expe­ri­ence that, given its diplo­matic pas de deux in winter, has to be acknow­ledged. The fact that states from Europe to the United States ignored this for a long time (so that lock­downs, ever­y­where and for ever­yone, became inevi­table) certainly refers to the weak­ness of the WHO, but is first and fore­most these states’ respon­si­bi­lity, driven by a convic­tion in the excep­tio­na­lity of western culture and tech­no­logy.

Inade­quate, yet Indis­pensable

This twofold obser­va­tion – WHO is not fulfil­ling its func­tions as would be desired, whereas a world health poli­tical orga­ni­sa­tion is indis­pensable – should lead to a reform agenda concer­ning both finan­cing (with, for example, fewer part­ners­hips of short dura­tion ear-marked funds and instead more contri­bu­tions to general budget), objec­tives (common health emer­gen­cies are not limited to epide­mics and biosafety problems) and gover­nance (inclu­ding other actors and forms of repre­sen­ta­tion than the demo­cracy of nation states). In a nuts­hell, the post­co­lo­nial critique that has been applied to Western narra­tives of progress and moder­nity, as being at “at once both indis­pensable and inade­quate” (D. Chakrabarty), applies to the WHO, its short­co­mings and its neces­sity.

While we are going through the pandemic and wait for the economic situa­tion allow for a reinven­tion of global health, we are at least enti­tled to hope that the members of the Euro­pean Union will learn from their own short­co­mings as well as from the lack of coor­di­na­tion between them in order to, in every sense of the word, reinvest in this same WHO. Other­wise, we should better stop comp­lai­ning about the fact that China, the world’s leading economic power and the second largest contri­butor to the WHO, is playing its part in the WHO as a soloist.

Claire Beau­devin, Jean-Paul Gaudil­lière, Chris­toph Grad­mann, Anne Lovel, and Laurent Pordie, eds. Global health and the new world order: histo­rical and anthro­po­lo­gical approa­ches to a chan­ging regime of gover­nance. Manchester: Manchester Univer­sity Press 2020.

 

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  • Christoph Gradmann is historian and professor for the history of medicine at the University of Oslo.

  • Jean-Paul Gaudillière is historian and senior researcher at the French state research institute Inserm and professor at the École des Hautes Études en Sciences Sociales in Paris.