By\u00a0Stephen Buranyi, The Long Read, London, 10 April 2020<\/p>\n
Attacked by Trump and ignored by many of its most powerful members, the World Health Organization is facing a major crisis \u2013 just at the moment we need it most.<\/em><\/p>\n I<\/span><\/span>f, like me, you have been confined to your home, glued to the news and nursing ever greater anxiety about the state of the world, you have probably become familiar with the sight of the World Health<\/a>Organization\u2019s director general, Tedros Adhanom Ghebreyesus, and his daily press briefings. Tedros, as he is known, is a calming presence in the midst of the crisis. Flanked by an international cast of scientists, he always seems confident that if we have hope, listen to the experts and pull together, we will get through this.<\/p>\n Watching this reassuring spectacle, it is possible to imagine a world in which every nation respects the WHO\u2019s authority, follows its advice and lets it coordinate the flow of information, resources and medical equipment across national boundaries to areas of greatest need.<\/p>\n That is not the world we live in. \u201cThe W.H.O. really blew it. For some reason, funded largely by the United States, yet very China centric,\u201d tweeted<\/a> Donald Trump on 7 April, summing up just one of the many lines of criticism the WHO is currently facing. It is not just Trump \u2013 even some of the WHO\u2019s supporters in government, academia and NGOs argue that since the start of the coronavirus crisis, it has caved in to nationalist bullies, praised draconian quarantine measures and failed to protect the liberal international order of which it is a linchpin. \u201cYou\u2019ve got a situation where it looks like WHO doesn\u2019t want to exercise its authority,\u201d said David Fidler, a fellow in global health at the Council on Foreign Relations and a regular consultant to the WHO.<\/p>\n Meanwhile, the WHO is desperately struggling to get its 194 member states to actually follow its guidance. The WHO\u2019s leaders are \u201cvery frustrated,\u201d said John MacKenzie, a virologist and adviser on the WHO\u2019s emergency committee<\/a>. \u201cThe messages come out loud and clear, and some disregard the warnings. The US largely did, the UK largely did.\u201d<\/p>\n On 11 March, the day Tedros declared the coronavirus a pandemic, he spoke darkly of \u201calarming levels of inaction\u201d from many countries. Pressed by journalists to name them, Mike Ryan, the usually no-nonsense Irish trauma doctor who heads the WHO\u2019s Covid-19 response, demurred. \u201cYou know who you are,\u201d he said, adding that \u201cwe don\u2019t criticise our member states in public\u201d.<\/p>\n There is a simple reason for this. For all the responsibility vested in the WHO, it has little power. Unlike international bodies such as the World Trade Organization, the WHO, which is a specialised body of the UN, has no ability to bind or sanction its members. Its annual operating budget, about $2bn in 2019, is smaller than that of many university hospitals, and split among a dizzying array of public health and research projects. The WHO is less like a military general or elected leader with a strong mandate, and more like an underpaid sports coach wary of \u201closing the dressing room\u201d, who can only get their way by charming, grovelling, cajoling and occasionally pleading with the players to do as they say.<\/p>\n The WHO \u201chas been drained of power and resources\u201d, said Richard Horton, editor of the influential medical journal the Lancet. \u201cIts coordinating authority and capacity are weak. Its ability to direct an international response to a life-threatening epidemic is non-existent.\u201d<\/p>\n At the same time, the international order on which the WHO relies is fraying, as aggressive nationalism becomes normalised around the world. \u201cAll the previous rules about global norms, public health and understanding of what\u2019s expected in terms of an outbreak has crumbled,\u201d said Lawrence Gostin, director of the WHO Collaborating Center on National and Global Health Law. \u201cNone of us know where this is leading.\u201d<\/p>\n T<\/span><\/span>he WHO was born during the moment of hopeful internationalism that followed the chaos of the second world war. The idea of global collaboration in fighting disease was not new \u2013 in the 19th century, at periodic International Sanitary Conferences, countries had standardised quarantine procedures for cholera and yellow fever \u2013 but the WHO constitution, adopted in 1948, envisioned a far grander global mission, nothing less than \u201cthe attainment by all people of the highest possible levels of health\u201d.<\/p>\n One of the WHO\u2019s favourite success stories is the role it played in eliminating smallpox, a disease that was still killing millions each year in the 50s, despite the existence of a vaccine. Although the WHO worked on immunisation research, its most vital role was organisational and diplomatic. In 1959, it convinced the Soviet Union to manufacture 25 million vaccine doses, which the WHO would distribute. Not to be left behind, the US donated millions of dollars to vaccination programmes, both directly and through the WHO. By the late 60s, every nation in the UN was sending a detailed weekly report to WHO headquarters on their number of smallpox cases and recent progress. And in 1979, WHO declared smallpox eradicated, a first in world history. The WHO didn\u2019t provide the most money, immunise the most people, or invent key technologies such as the bifurcated needle<\/a>, but it is hard to imagine smallpox having been defeated without it.<\/p>\n If the story of smallpox eradication shows the WHO acting as something like an international ministry of public health, it doesn\u2019t explain its current position as an emergency service, surveying the world for disease outbreaks and springing into action to contain them. That is a more recent addition to its portfolio, which came after a period, in the 80s and 90s, when the WHO seemed to be losing its earlier dynamism. The diseases it was partly created to address \u2013 smallpox, yellow fever and the plague \u2013 had either been eradicated or were in decline, and it was slow to identify new threats such as HIV\/Aids. Under the leadership of Dr Hiroshi Nakajima, from 1988 to 1998, the organisation stagnated, and some member states complained about poor management and alleged petty corruption.<\/p>\n Two things happened at the turn of the century that would shape the WHO we now see tackling the Covid-19 crisis. In 1998, the fiery former prime minister of Norway, Dr Gro Harlem Brundtland, was elected director general. And in 2002, a farmer in China\u2019s Guangdong province became sick with a deadly, never-before-seen respiratory disease that quickly spread among the hospital staff who had treated him, and went on to become the first pandemic of the newly globalised 21st century: one that arose suddenly, had no treatment or cure, and spread with the speed and reach of international business.<\/p>\n G<\/span><\/span>iven the WHO\u2019s sprawling structure, vague mandate and reliance on diplomacy, its director general holds immense power to shape it. Even before she took on the role, Brundtland was comfortable on the world stage. \u201cI was already a political leader, and I was used to this kind of authority,\u201d she told me. Like her friend Kofi Annan, the charismatic UN leader, Brundtland believed that international bodies should be prepared to lead when necessary, rather than being bossed around by powerful nations. \u201cIf the job is to direct and coordinate global health, it\u2019s not a question of what one or several governments ask you to do,\u201d she said. \u201cWe are working for humanity.\u201d<\/p>\n Brundtland pushed the WHO to use its local contacts, diplomatic channels and the emerging internet to locate potential outbreaks, all of which made the organisation less reliant on national governments for information. Within just a few years, this strategy proved its worth. In November 2002, when the Chinese government became aware of the first cases of a novel respiratory disease, later named Sars, it failed to alert the WHO. But, as part of Brundtland\u2019s new approach, WHO staff were monitoring Chinese medical message boards and news media anyway, and were aware of what was then thought to be an atypical pneumonia outbreak. Adding to their suspicions, on 10 February 2003, David Heymann, who was then executive director of the WHO\u2019s communicable diseases cluster, received an email from the son of a former WHO staff member in China warning of a \u201cstrange contagious disease\u201d that had already killed 100 people, but which was \u201cnot allowed to be made known to the public\u201d. The WHO took the information it had to China, which made its first official report to the WHO the next day.<\/p>\n Although the WHO had no formal powers to monitor and censure its members, Brundtland wasn\u2019t shy about doing so anyway. In the ensuing months she would accuse China of withholding information, claiming that the outbreak might have been contained \u201cif the WHO had been able to help at an earlier stage\u201d and exhorting the Chinese to \u201clet us come in as quickly as possible!\u201d With remarkable speed, China fell in line and shared its data with the WHO. \u201cAfter her statements to China, no other countries hesitated,\u201d said Heymann.<\/p>\n In March 2003, as the disease spread \u2013 reaching Hong Kong, Vietnam and then Canada \u2013 for the first time in its history, the WHO issued advice against travelling<\/a> to affected areas. (Before then, the decision to advise on travel had always been left up to member states.) Despite having no formal powers to ground planes, the measures worked. \u201cPassengers and flights dropped dramatically as soon as we issued the recommendations,\u201d said Heymann.<\/p>\n Brundtland\u2019s approach was not always popular, and some bridled under this new upstart WHO. \u201cIt wasn\u2019t just China,\u201d Brundtland told me. \u201cThe mayor of Toronto [Mel Lastman] flew to Geneva to tell us take down the travel recommendation \u2013 while at the same time he was not containing the outbreak. He had people with Sars riding around the subway, no contact tracing, no following up. He couldn\u2019t accept we were telling him what to do!\u201d<\/p>\n The WHO\u2019s response to Sars was considered a huge success. Fewer than 1,000 people worldwide died of the disease, despite it reaching a total of 26 countries. The pandemic was defeated not with vaccines or medicines, but with NPIs, or \u201cnon-pharmaceutical interventions\u201d in WHO parlance: travel warnings, tracking, testing and isolating cases, and a huge information-gathering operation across multiple countries, all made possible by the WHO\u2019s willingness to wield authority that it had, in a sense, created simply by speaking it into existence. \u201cBrundtland did things the WHO had no authority doing. She just did them,\u201d said Fidler. \u201cShe sort of used Sars as a way to test drive some very radical changes.\u201d<\/p>\n \u201cAfter Sars, the WHO\u2019s position was essentially: that was great, let\u2019s formalise it,\u201d said Clare Wenham, a professor of global health policy at LSE. In 2005, the WHO drew up a new version of the International Health Regulations (IHR)<\/a>, the central legal document that all member states are bound by. According to Fidler, the updated IHR, which is in force to this day, is a radical document. It asks its members to prepare for public health threats according to standards set by the WHO, and to report any outbreaks and all subsequent developments. It also allows the WHO to declare a public health emergency of international concern (or PHEIC, pronounced, incredibly, \u201cfake\u201d), using its own information, over the objection of any single country. During an emergency, countries are expected to take the lead from the WHO\u2019s guidelines and report any deviations to the organisation. All of these requirements, bar the reporting of outbreaks, were new.<\/p>\n But the document stopped short of giving the WHO real power if states refuse to comply. \u201cThe WHO isn\u2019t Nato, it\u2019s not the security council,\u201d said Gian Luca Burci, who was the WHO\u2019s legal counsel until 2018. The US, fixated on bioterrorism after 9\/11, supported giving the organisation some extended powers, but was opposed by Brazil, Russia, India and China, which were wary of US influence. There was a general reluctance to hand an international organisation any more power. \u201cWHO members were happy with the actions that were taken during Sars, but there was definitely a sense afterward of \u2018What if that was us in China\u2019s spot?\u2019,\u201d explained Catherine Worsnop, a professor at the University of Maryland School of Public Policy. In short: thanks for stopping the pandemic, but we don\u2019t want to be told what to do.<\/p>\n I<\/span><\/span>f the WHO has seemed at times weak or tentative \u2013 very un-Brundtland-like \u2013 in its handling of the coronavirus crisis, it is partly because of its bruising experiences during the past decade. From 2009 onwards, the WHO faced condemnation from the press and the international community for its handling of successive crises, all during a decade when the financial and diplomatic order that sustained it began to break down.<\/p>\n First, there was the outbreak of H1N1, or \u201cswine flu\u201d. The novel influenza virus was discovered in Mexico in March 2009, and by June, when the WHO declared a pandemic, there were more than 28,000 cases in 74 countries. Over the next year, the WHO coordinated the global response \u2013 less aggressively than during Sars \u2013 and on 10 August 2010, it declared the pandemic over. Almost immediately, the WHO\u2019s approach came under scrutiny. The death toll \u2013 18,500 confirmed deaths worldwide \u2013 was far lower than initially expected, particularly given the disease reached more than 200 countries. \u201cSuddenly you have people saying: \u2018Wait a minute, you really cried wolf on this,\u2019\u201d says Wenham. The media and several prominent European politicians demanded inquiries as to whether the WHO had mistakenly rung the alarm, and \u201ccost huge amounts of money and frightened people unnecessarily\u201d, as Paul Flynn, the former Labour MP who chaired one of the inquiries, told the Times in 2010.<\/p>\n To this day, opinions are split as to whether H1N1 was a crisis headed off, or a false alarm. \u201cThe WHO is always at risk of being criticised as doing too much or too little,\u201d said Keiji Fukuda, the former WHO assistant director general who led the H1N1 response. Most of the former WHO staff and academics I spoke with agreed, proposing some version of the following as an iron law of public health: act slowly and you will be criticised for failing to stop preventable deaths; act aggressively and stop an outbreak before it becomes serious, and you will be accused of having overreacted. (After all, in the latter case, nothing too bad happened, so what was the big deal in the first place?)<\/p>\n Fidler, who largely approves of WHO\u2019s quick action during H1N1, believes that the backlash led the WHO, which was then under the command of director general Margaret Chan, to become too tentative about calling for action in the future. This was a period when the fallout from the 2008 financial crisis was also starting to take its toll on its budget. \u201cThere was a big funding shortfall,\u201d said Andrew Cassels, director of strategy at the WHO between 2008 and 2013. \u201cCuts made to the emergency response programmes, personnel cuts.\u201d The funding gap stood at nearly $300m in 2012. Entire offices were shut, including a team of social scientists working on pandemic response.<\/p>\n When the Ebola outbreak struck west Africa in 2014, the combination of the WHO\u2019s greater caution and reduced budget resulted in disaster. In contrast to the previous pandemic, this time the WHO was slow to act, and was widely perceived to have lost control of the situation. In the end, the US and several other nations deployed<\/a> more than 5,000 military personnel at the request of the affected countries, and an ad-hoc UN committee was created to take over responsibilities from the WHO. The outbreak eventually killed 11,310 people, the vast majority in just three countries \u2013 Guinea, Liberia and Sierra Leone \u2013 paralysing their health systems for months, and causing panic across the world. Prominent scientists judged<\/a> the WHO\u2019s response an \u201cegregious failure\u201d.<\/p>\n Much of the blame fell on Chan herself. She appeared shell-shocked, stressing to the press that the WHO was a technical advisory body, and that it was national governments that had ultimate responsibility for their citizens\u2019 health. \u201cShe wanted the WHO to be an apolitical agency \u2013 more like technical support. There was a hesitancy there to push the full powers of the WHO,\u201d said Sara Davies, a professor of global health at Griffith University in Australia.<\/p>\n The bold, proactive culture established after Sars had seemingly faded. Fidler believes that by delaying calling Ebola an emergency, and thus failing to organise an international response at a crucial moment, the WHO\u2019s leadership had shown they \u201cno longer had any faith in their authority\u201d.<\/p>\n T<\/span><\/span>oday, under Tedros, the WHO finds itself in uncharted territory. Not only is it facing by far the biggest pandemic in its history, it is also having to defend itself from the nations on which it most depends. \u201cIn my 25-plus years of working on global health issues, I cannot recall the leader of a prominent developed country threatening to punish WHO in the manner President Trump did,\u201d said Fidler, referring to the recent press conference in which Trump suggested putting \u201ca very powerful hold\u201d on US contributions to the WHO. In the same press conference, Trump accused the WHO of concealing information, being too slow to react to the virus, and, above all, showing favouritism towards China.<\/p>\n Since the crisis began, Tedros has been repeatedly accused of being soft on China. Senator Marco Rubio recently told<\/a> Fox News that the Chinese government had \u201cused the WHO to mislead the world\u201d, and claimed that the WHO \u201cis either complicit or dangerously incompetent\u201d. The US senator Rick Scott put it more bluntly, accusing the WHO of \u201chelping Communist China cover up a global pandemic\u201d. (Tedros, meanwhile, has warned of the dangers of politicising the virus<\/a>.)<\/p>\n Until very recently, the WHO was seen as a relatively neutral arena for China to extend its power. \u201cChina likes to find ways within the global system to give it a leading and benevolent image. The WHO was an uncontroversial place to do it,\u201d said Rana Mitter, the director of the University of Oxford China Centre. No longer. The extent of the initial coverup is still unclear, but there is no question that at least at the local level, Chinese officials knew about the outbreak of a novel disease for weeks before it was reported to the WHO. During that time, Chinese doctors were prevented from speaking out.<\/p>\n John MacKenzie, the WHO\u2019s emergency committee adviser, told me that the organisation was \u201ca little misled\u201d about the Wuhan outbreak. He says that by the time the government alerted the WHO on 31 December, scientists in China had already determined via genome sequencing that the outbreak was caused by coronavirus. Yet the government didn\u2019t confirm that until 7 January and the full genome sequence was not officially shared until 12 January. \u201cThat\u2019s very slow,\u201d MacKenzie told me. \u201cFor at least two weeks, we could have been making far more kits and so on for testing.\u201d MacKenzie added that the number of cases officially declared by the Chinese in the first week \u2013 59 in the week ending 5 January \u2013 was \u201cnowhere near as many cases as you\u2019d expect\u201d. (The statistics released by the Chinese government continue to be questioned, with some reports<\/a> suggesting they may have seriously understated the number of coronavirus deaths.)<\/p>\n Despite mounting frustrations \u2013 in mid-January, China also refused the WHO\u2019s request to send a team of scientific observers to Hubei province, the centre of the outbreak \u2013 Tedros has never come close to doing what Brundtland did and calling China out. Instead, on 28 January, he had a closed-door meeting with Xi Jinping in Beijing, and two days later, he praised Chinese efforts to contain the disease, declaring that China is \u201csetting a new standard for outbreak control\u201d. That same day, 30 January, the WHO declared a Pheic, and began issuing prescriptions to countries around the world. On 8 February, China finally allowed WHO observers into the country. For Tedros\u2019s supporters, this was vindication of his strategy of keeping China onside. For his critics, it was too little, too late.<\/p>\n Elected as WHO director general in July 2017, Tedros was supported by a bloc of African and Asian countries, including China, which has considerable influence with those members. (Tedros is himself from Ethiopia, where he served as health minister and then foreign minister between 2005 and 2016.) It was a \u201creally nasty\u201d election, said Davies, in which the powers that have traditionally shaped the WHO, such as the US, UK and Canada, lent their support to one of Tedros\u2019s rivals, the British doctor David Nabarro. During the campaign, Tedros was criticised for having served in a repressive government with a poor human rights record, and one of Nabarro\u2019s backers even accused<\/a> Tedros of covering up a cholera epidemic during his time as health minister. (Tedros denied the<\/a> claim, describing it as a \u201clast-minute smear campaign\u201d, while Nabarro told the New York Times that he had never authorised his team to make this accusation against Tedros.) In response, Tedros\u2019s supporters mounted \u201ca collective pushback\u201d, said Davies, against the UK and its allies, eventually winning out. Tedros became the first director general from a so-called developing country since the Brazilian Dr Marcolino Gomes Candau in 1953.<\/p>\n While his background is in politics, Tedros is not forthright or confrontational like Brundtland. In Ethiopia, his political party, the Tigray People\u2019s Liberation Front (TPLF) was mostly comprised of ex-revolutionaries, men that \u201cseemed carved out of a rock\u201d, said Fantu Cheru, a professor at American University and former advisor to the Ethiopian government. Tedros was different \u2013 jovial and accessible, said Cheru, and able to make personal connections easily. \u201cHe is not very ideological, he believes he can work with anyone,\u201d said Mehari Taddele Maru, a professor at the European University Institute in Florence, Italy. Cheru also sees Tedros as a pragmatist. \u201cHe\u2019s not in the Chinese pocket. The Americans in particular wanted to destroy his image. Tedros knows how this game works. You need to have more allies than enemies, and those allies may not have a good track record.\u201d<\/p>\n \u201cI don\u2019t think Tedros did anything previous director generals would not have done,\u201d said Anthony Costello, the director of the UCL Institute for Global Health. \u201cHe needed a good relationship with China in order to get in.\u201d Even Lawrence Gostin, who has been a prominent critic of Tedros in the past, told me that \u201chis high praise for China is understandable. He is seeking to coax China into cooperation.\u201d He went on to note, though, that this strategy \u201cdoes risk the credibility of WHO as an objective agency.\u201d<\/p>\n If the WHO thought it could sacrifice a bit of its credibility \u2013 overlooking China\u2019s obvious blunders in December and January in exchange for its compliance in February \u2013 and move on, it was mistaken. The argument over China\u2019s influence has been raging for weeks, not least since the government of Taiwan claimed<\/a> that the WHO had ignored its own early reports of human-to-human transmission of coronavirus as part of a larger history of appeasing China \u2013 which has blocked Taiwan from joining the WHO (and the UN) for decades.<\/p>\n Now that Trump, scrambling for an answer to explain why the US now has more cases<\/a> of coronavirus than any other nation, has alighted upon the WHO and China as his preferred scapegoats, these questions will not go away. \u201cI don\u2019t think we will see the US government cut off funding,\u201d said Fidler. \u201cBut what\u2019s happened with this pandemic \u2013 with the WHO caught between the US\/China rivalry \u2013 is not a good omen for the WHO going forward.\u201d<\/p>\n W<\/span><\/span>hile the focus has been on what happened between China and the WHO in January, in epidemiological terms the crisis has moved on. Covid-19 has spread fastest and furthest in the US and Europe, through the very rich nations that largely fund and staff the WHO. Before the outbreak, the WHO struggled to get these same nations to prepare for future pandemics. Now the pandemic is here, and they are at the centre of the crisis, the WHO has been unable to keep them following its advice.<\/p>\n Richard Horton of the Lancet said that after the WHO declared a public health emergency, \u201ccountries, especially western countries, didn\u2019t listen. Or didn\u2019t seek to understand what was actually taking place in China.\u201d On 5 February, the WHO asked for<\/a> $675m to fund its Coronavirus response through to April. Anthony Costello of UCL said that when he met with Tedros on 4 March, the WHO had received only $1.2m. (Tedros announced last week that the funding goal had finally been reached, around the time the number of worldwide cases passed 1 million.)<\/p>\n Even the decision to declare a pandemic on 13 March \u2013 a largely rhetorical distinction, since calling a Pheic already requires WHO members to respond \u2013 was calculated to wake its member states up. In the UK the Premier League was still playing games, and the previous week the US had held primary election contests. \u201cThey declared a pandemic because countries weren\u2019t taking the advice,\u201d said Adam Kamradt-Scott, a professor of global health at the University of Sydney.<\/p>\n The WHO stresses that the ideal response to the crisis is relatively simple. Individual states should limit public exposure, especially by tracking and tracing all known cases \u2013 a strategy that worked in South Korea and appears to be working in Germany. On an international level, states should share scientific information and resources. These are the mantras Tedros goes back to in his briefings: \u201cTest test test\u201d and \u201csolidarity solidarity solidarity\u201d.<\/p>\n But countries have repeatedly ignored WHO advice. In the UK, the response has been erratic, lurching between the WHO\u2019s norms and its own strategies, such as the now-discredited pursuit of \u201cherd immunity\u201d. The US didn\u2019t recommend school closures or avoiding travel until 16 March. In Sweden<\/a>, restaurants are still open.<\/p>\n Many wealthy nations have not only pursued their own national strategies for public health, but have also withdrawn from the globalised world of diplomacy and trade that they themselves set up. Earlier this year, for instance, the NHS ordered<\/a> millions of masks from a French company named Valmy SAS. But in early March, the French government requisitioned all masks produced within the country, so the masks never reached Britain. This week, Germany accused the US<\/a> of seizing a shipment of masks bound for Berlin from a port in Thailand; while Germany previously sent inspectors<\/a> to the factory of an American company in J\u00fcchen to ensure their medical masks weren\u2019t being exported against government orders.<\/p>\n The WHO is battling against a breakdown in international cooperation that is far beyond its capacity to control. \u201cGovernments have retreated to national policies, and this problem predates this crisis,\u201d said Clare Wenham, the health scholar. States have been turning away from international institutions for a long time. The WHO hasn\u2019t driven globalisation in the same way as the WTO or IMF, but in a way it has administered it \u2013 quietly promising to take on the outbreaks that arise in an industrialised and interconnected world, and relying on the often unspoken norms of international collaboration that underlie it.<\/p>\n Ironically, it is most needed now, at a time when faith in the other administrators and overseers of the global order are in decline \u2013 a trend that Covid-19 only seems to be accelerating. \u201cAs it\u2019s gone on, you see the WHO becoming less important,\u201d said Wenham. \u201cNo one is thinking about reducing the global numbers, only their own. The WHO is a global force, but people aren\u2019t thinking globally.\u201d<\/p>\n