In parts one, two and three of this series on the World Health Organisation, we looked at its poor response to the Covid-19 pandemic, its history and financial mismanagement, its leadership and its road to failure. In this final part, we’ll consider how it should be reformed.
On the very day US president Joe Biden took office, he signed an executive order to reverse former president Donald Trump’s decision in June 2020 to withdraw his country’s membership of the World Health Organisation (WHO). Two months earlier, he had frozen the country’s financial contribution to the WHO, which makes up the largest single share of its funding.
Country membership fees, or ‘assessed contributions’ are mandatory payments calculated as a small share of member countries’ GDP. This accounts for about 20% of the WHO’s funding. Voluntary contributions make up the bulk of the organisation’s budget, and in some cases are limited to specific purposes. Besides member states, they can come from other UN organisations, intergovernmental organisations, philanthropic foundations, the private sector, or any other source.
The US contribution made up 20% of the WHO’s total funding in the 2018 to 2019 biennium, and its voluntary contribution accounts for 15% of all voluntary contributions.
Trump had been offended by the WHO’s close ties to China, which had refused entry to a WHO team investigating the origin of the virus that causes Covid-19, and has been accused of covering up the nature and extent of the original outbreak in the city of Wuhan, as well as silencing doctors and other whistle-blowers.
As we have seen in earlier instalments of this series, Trump’s concern was largely justified.
The WHO will not reform itself
In broad terms, the Biden White House does not disagree. ‘The WHO is a very imperfect organisation in need of reform,’ said Antony Blinken, Biden’s nominee for Secretary of State, during a Senate confirmation hearing on Tuesday, according to The Hill. The move to rejoin the WHO was motivated by the belief ‘that we’re going to be in a much more effective position to advance that reform of the WHO if we’re there at the table than if we’re outside the organisation’.
This view is naïve. After the Ebola debacle, in which the WHO acted reactively and belatedly, instead of proactively curbing the spread of the epidemic, experts demanded that the organisation be overhauled or dismantled. The WHO itself agreed to a long list of reform measures. It has failed to implement most of them, however, even though throughout this time the US had a seat at the table.
Without extraordinary pressure, the WHO will not reform itself from the inside.
There has been no news on whether the funding freeze will be lifted, but it seems likely that it will. If reform is what the Biden administration wants, it would be wiser to make the voluntary contribution of the US conditional upon the support of other countries for its reform proposals.
After all, the WHO is entirely democratic, with every member country having equal voting rights. On its own, the US will achieve very little, as was evident when its preferred candidate for director-general lost to the candidate supported by the larger club of socialist, corrupt and authoritarian countries of Africa and Asia.
Lifestyle diseases
The most important reform that is needed is to dramatically restrict the WHO’s mandate. Its original purpose was to help combat communicable diseases that affected multiple countries and required international cooperation. It was once very successful at doing so. It no longer is.
The major reason for this is the diversion of its budget and attention towards non-communicable diseases and outright political advocacy.
Addressing public health issues such as tobacco, alcohol, sugar, salt, exercise or dietary fat does not require international cooperation.
In many cases, it isn’t even clear what the best medical advice looks like. Low-fat dietary guidelines, for example, notoriously coincided with a sharp uptick in obesity rates worldwide. The war on salt has little basis in science. The WHO’s attempts to get vaping drawn into tobacco-control legislation are based not only on poor science, but actively undermine the public health objective of tobacco harm reduction.
Even when the science is much clearer, such as in the case of tobacco, it isn’t at all clear why there ought to be a global authority prescribing how countries should deal with the issue, or why ‘tobacco control’ requires an international treaty.
Just as with sugar and alcohol, the WHO, instead of promoting information campaigns and strengthening public health measures, typically deals with products it deems undesirable in an authoritarian way.
Command and control
There is no recognition that everyone is different. Some people have no issues at all with sugar. Many have no problems with alcohol. Yet authoritarian measures treat all as if they were in the minorities for whom these products do constitute health risks.
The WHO tends to recommend measures such as legal prohibitions, regulatory restrictions, conditional licensing, advertising bans, mandatory labelling, and most notably, high excise taxes.
The excuse to raise more taxes, of course, appeals to member state governments. It is no surprise that many are happy to use the WHO’s authority to justify broadening their excise tax base. Many WHO member governments are themselves strongly authoritarian, illiberal or patriarchal in nature, and believe citizens ought to be commanded, not persuaded. This tendency is reflected in how the WHO operates.
This conflicts with the WHO’s original mandate of dealing with diseases that have international consequences and require international cooperation.
The illiberal approach to so-called ‘lifestyle diseases’, as we have seen in previous instalments of this series, increasingly draws funding and bureaucratic attention away from communicable diseases. It actively undermines the ability of the WHO to function as a global coordinator of emergency outbreak response.
An even bigger drain on the WHO’s resources is the sharply escalating budget allocated to promoting universal healthcare systems. Just as with non-communicable diseases, this ought to be a function of individual governments, dependent on the democratic will of their people. Whether healthcare is provided privately, by the state, or by a combination of the two, is a purely domestic matter that requires no international cooperation or coordination. It is, frankly, none of the WHO’s business.
Slimming down
Although the WHO is happy to pronounce on the undesirability of obesity among the citizens of member countries, the organisation itself has grown fat and lazy. We have seen that its staff, on average, earn more than the per-capita GDP of even the richest country in the world, Luxembourg.
The WHO maintains a physical presence in almost every country in the world, with all the associated expenses of lavish offices and well-paid staff. Above this, it maintains a phalanx of regional offices. This infrastructure consumes an estimated 70% of its entire budget.
In the 21st century, when anyone on the planet can email and video-conference with WHO experts at regional or headquarters level, there is simply no justification to maintain such an expensive footprint.
The WHO’s overhead costs must be dramatically reduced before its complaints that its epidemic response programmes are underfunded can be taken seriously.
Slimming the organisation down will also make it much more efficient, and address the excessive bureaucracy that often delays its responses, with deadly results.
Depoliticising the WHO
The WHO was too concerned that its intervention in the Ebola epidemic might be construed as a ‘hostile act’. The organisation, and especially its director-general, Tedros Adhanom, has proved to be much too deferential to the Chinese regime, which turned it into a political football between the world’s superpowers. The leadership contest between Tedros and David Nabarro was, in reality, not a contest about who might be the most competent person for the role, but was a power struggle between the liberal democracies of the West and the authoritarian regimes of the Global South.
Perhaps the most egregious example of the WHO playing politics was in how the organisation handled questions, warnings and advice from Taiwan. Formally, the WHO, under pressure from China, bars Taiwan from membership. It therefore has no standing with the organisation.
In December 2019, Taiwan wrote to the WHO asking for information on the newly discovered coronavirus, and the possibility of human-to-human transmission. The WHO confirmed receipt of the letter, but flatly ignored its contents. Taiwan saw the pandemic coming, and took action even before China did. The WHO was not interested. Its containment measures resulted in one of the lowest infection rates and mortality in the world. To date, the island of 23.5 million people has seen only 872 cases and seven deaths. The WHO did not hold it up as an example for the rest of the world. It played politics with people’s lives.
The WHO needs to be depoliticised. It should interact with all its members without fear or favour.
The organisation adopted revised International Health Regulations in 2005, which commit member countries to cooperate with it ‘to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks and that avoid unnecessary interference with international traffic and trade’.
Yet the WHO has no means of enforcing these regulations. When member countries fail to notify the WHO in a timely manner, fail to disclose material evidence needed to determine a coherent response to an outbreak, or refuse to admit WHO experts to investigate epidemics, it is entirely impotent, even though such actions cause demonstrable harm to other countries.
The WHO should do much less, but in its more limited role, it should have the power to execute its mandate fairly and effectively.
Its powers should be carefully circumscribed, however. Being able to enforce public disclosure and transparency in dealing with disease outbreaks is a far cry from being able to violate the right of sovereign nations to respond to epidemics as they see fit.
Revise funding
The WHO relies heavily on earmarked voluntary contributions. This limits its ability to budget for the public health emergencies for which it was created, while incentivising it to broaden the scope of its activities to attract new funding.
While it is hard to argue that, for example, a philanthrophic foundation dedicated to the eradication of malaria should not be able to specify what its donation is used for, the same freedom also permits governments to place conditions on how the WHO chooses to use its funds. The US, for example, has a reputation for cutting funding to programmes that pay for contraception or safe abortions.
The entire funding mechanism of the WHO needs to be revised. Its base programme budget should be strengthened, and it should get more say in how voluntary contributions are spent.
Fundamental restructuring
The WHO relies almost entirely on medical and public health experts. In making recommendations about national policy decisions, it could benefit greatly from beefed-up expertise from economists, lawyers, logistics experts, political scientists, urban planners, sociologists and technology experts.
It took the WHO until October 2020 to roundly condemn lockdowns as a ‘ghastly global catastrophe’ whose only consequence is to ‘make people an awful lot poorer’. Instead of commending China on its unprecedented and untested lockdown strategy, the WHO should have considered the social, economic and political consequences far sooner.
Finally, the organisation needs to be a lot more transparent and accountable. Changing how budget line items are described merely serves to obscure trends in how the organisation spends its limited budget. If its own auditors describe half of the WHO’s functions as unsatisfactory or worse, how can the general public have any confidence that the organisation is well-run, and is worthy of their tax funding?
These reforms are not minor adjustments to improve the WHO. They will require a fundamental restructuring of the organisation. It needs to be rebuilt from the ground up, with a narrow focus in mind, and the ability to execute well on that specific mandate.
Since it is clear it will not reform itself, the incoming Biden administration could do worse than to use the almost $1 billion it contributes to the WHO as collateral to ensure that the organisation delivers on its promises to reform.
The next global pandemic will come, five, ten or twenty years from now. When it strikes, it would be comforting to know that a new, improved WHO stands ready to nip it in the bud.
The views of the writer are not necessarily the views of the Daily Friend or the IRR
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