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Inade­quate, yet Indis­pensable: The WHO and the History of Global Health

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.

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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.