How the US can help WHO change for the greater good —

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The coronavirus pandemic has shown what public health experts have known for a while: The World Health Organization (WHO), the public health offshoot of the United Nations, needs to function better in order to keep the world healthy. President-elect Joe Biden will have a chance to help fix it—but that might mean letting the US have less influence over the organization.

In July, US president Donald Trump formally announced that the country would be withdrawing from WHO. The reason, he said, was the organization’s inadequate response to Covid-19 and other health crises, as well as its inability to stand up to China. When the outbreak spread was still limited to China, the country appeared to block international researchers’ access to critical data, locations to help discover the source of the virus, and the virus’ genetic code. And though WHO did its job by sharing the information it was given, some critics say it didn’t push hard enough for transparency.

But many public health experts agree that withdrawing from the world’s premier public health organization would only hurt the US’s response to the pandemic. Now, president-elect Joe Biden has said that he intends to keep the US in WHO (it takes a year to formally withdraw, so even after Trump’s announcement the US wouldn’t fully have exited until July 2021).

Problems in the organization remain. Some public health officials have criticized the agency for being slow to declare the Covid-19 outbreak a pandemic, and to communicate that the virus is primarily airborne. For WHO to be the most effective version of itself, its members countries will need to reconsider how the agency is funded, and what their own relationship should be towards global health.

“We can’t go back to business as usual,” says Kelley Lee, a professor of public health at Simon Fraser University. “After this pandemic, what we’ve all learned is we have to look at how WHO works and how member state structure works. How do we make sure the organization serves all the member states, not just one voice?”

A broad mandate

WHO’s weaknesses today are an unintended consequence of its architecture, which was designed for the world of 70 years ago.

Founded in 1948, the organization was part of the push for global governance at the end of World War II that also created the United Nations. Its constitution (pdf) calls for an agency whose goal is “the attainment by all peoples of the highest possible level of health.” That breaks down into 22 different functions that include educating the public about health, helping countries navigate health-related challenges, and furthering efforts to study and treat or cure all forms of disease.

Up through the 1990s, the organization was well respected and generally apolitical, says Lee, who has been studying the agency for three decades. ”Since then it’s been criticized for being too bureaucratic, for not able to be nimble when it needs to be,” she says.

This isn’t the organization’s fault per se—it’s because its 194 member countries have outlined its priorities, which are simply too numerous to do well. The juggling act only gets harder during a pandemic, when WHO is tasked with gathering and sharing information about global outbreaks with all members, and providing those countries with advice on how to handle the situation. It also serves to coordinate countermeasures, including therapeutics and vaccines.

“I think there has got to be a process by which WHO can pare back its mission, to be a bit more tightly focused and more organized around what it wants to do,” says Ashish Jha, dean of the Brown University School of Public Health. “Right now WHO wants to be all things to all people, and no organization can succeed at doing that. I have been arguing for years that WHO should be effective, focused, and smaller”—not in terms of its budget, he clarifies, but more concentrated on the things only it can do.

During pandemics or otherwise, that critical task is to set norms for global collaboration around science.

Put your money where your health is

If WHO is to evolve, the US may need to reconsider its relationship with the organization. So far, the US has played a major role in setting WHO’s priorities. “I know the Trump administration has consistently argued that China has been the big player in WHO. But actually, if you look on every measure, it’s been the US that has had the biggest voice over the past 70 years,” Lee says.

The US is WHO’s biggest benefactor. It spent US$893 million to fund the organization’s 2018/2019 term. But just 27% of that total was “assessed contributions”—dues that all member states have to pay. The US’s extra funding is allocated towards specific projects, including those tackling polio, preventable diseases, and tuberculosis.

Those “specified voluntary contributions” from all member countries made up 77% of the UN’s overall funding in 2018/2019. That leaves just 22% of its budget, a still notable $1.3 trillion, for its leadership to allocate as it sees fit.

That breakdown is in large part because of the US’s influence. “Donor countries, particularly the US, have pushed for the WHO’s budget to be frozen,” Lee says.

That strategy didn’t fit into the American ethos of small government. In the 1980s, the Reagan administration pushed for a freeze in assessed contributions across the UN in the name of austerity, Lee says. Further freezes to keep up with inflation came in the 1990s, under the banner of “zero nominal growth.”

As a result, WHO struggled with its funding, Lee says, and it began taking money from relatively new but moneyed global health nonprofits with their own agendas.

Not that it’s a bad thing to have more money. But by taking donations from nonprofits, more and more of WHO’s budget was earmarked for specific purposes, leaving the organization with less for core operations and critical functions that aren’t as appealing to donors.

“This is to say, no, the organization is not performing the way it’s been designed to or the way we need it to perform,” Lee says.

This money gets to a key tension of WHO’s existence: Is it a membership organization or is it the world’s public health agency? “Ninety percent of the time those two identities are totally compatible with each other. But for the 10% of times they are not, those are the most important,” Jha says. When member countries are misbehaving in ways that are bad for global health, should WHO push back on them as a global public health agency would, or work to appease those countries, acting more like a membership organization?

Historically, WHO’s leaders have opted for the latter. The organization’s lack of pressure on China has been the primary complaint of the US, and of other critics. And since WHO doesn’t have a way to penalize countries that don’t cooperate, it’s had to work to stay in their good graces.

But member nations are increasingly calling for it to take a bigger stand against those countries causing trouble. Soon, that might mean standing up to the US, too.

A global proxy battle

There’s no question that Biden’s intended return to WHO will be a good thing for the organization. American intellectual leadership and science have always made up a critical part of WHO, Jha notes, and “it’s a good thing for global health when America is engaged.”

There are also benefits for the US, including a place to exercise and augment its soft power. Allowing the exit to finalize in July 2021 might create a power vacuum that countries like China and Russia to step in and fill. “The Chinese government has a great opportunity to make itself look good after some bad PR this year. If it increases the funding to WHO and shares a vaccine in a helpful way, it could increase its influence,” Lee says. More concretely, rejoining would allow the US to participate in conversations around the intellectual property and distribution of vaccines.

But when Biden rejoins WHO, he might find an organization that has reshaped itself away from US influence.

When the Trump administration announced its intention to withdraw from WHO, member states vowed to make up the funding deficit. Reforms could also make the organization less beholden to individual countries. In the past, some member countries have suggested giving WHO the power to sanction nations that don’t cooperate; more recently, Germany and France have suggested increasing the amount owed in assessed contributions to give WHO more autonomy. Suggestions in the past elicited little interest among member nations, but the coronavirus pandemic may have changed that.

The US can play a constructive role in that shift by accepting that it is just one of many nations in WHO, and that it’s safer if every nation has an equal voice. “If the Biden administration is serious about an effective WHO, it has to step back. It has to allow the organization to have more authority and more funding that it controls,” Lee says.

Jha fears that Trump’s actions have made it less likely for WHO leadership’s to push back against member nations, since there’s now precedent for disgruntled countries to bow out. Biden could counteract that, though, by re-engaging the US with WHO with a long-term commitment in mind.

That wouldn’t just be good for the US—it would be good for the world. There will be more pandemics, but there are other glaringly obvious collective action problems, such as climate change, that threaten the wellbeing of human beings and the societies they’ve built. We need to come together to face these issues, Lee says, and global institutions are the best way to do that.

“Now we have evidence that this is really needed, and WHO as it’s structured as a member organization may be obsolete. We may need something quite different,” she says. “We have a globalized, interconnected world, but we’re not [yet] seeing…the world as a planet, not just a collection of countries. This is a historical moment. Your generation going forward may have a different view of the world.”



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