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.
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.
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
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.