(Re-)Making a People’s WHO

As global health experts, politicians, civil society organizations, and six of the G7 leaders rally to support the World Health Organization (WHO; https://bit.ly/3gP9Dyj) and counter the US administration’s discrediting of the agency and suspension of funding, a moment of reflection is warranted.

Undoubtedly, WHO is a crucial player (https://bit.ly/2U9s7Qh) in steering us through the COVID-19 pandemic, cooperating with member countries in developing pandemic preparedness plans (including for subsequent waves of the disease); gathering, analyzing, and disseminating critical epidemiological data; conveying sound, scientifically grounded policies and advice; establishing guidelines around testing, physical distancing, and other public health measures; setting norms on data collection and information sharing; and supporting research on drugs and vaccines. If properly funded and granted the power by member countries, WHO has the potential to amp up its transport of personal protective equipment and other essential supplies to protect frontline workers and serve as an international coordinator for the ethical and equitable distribution of diagnostics, vaccines, therapeutics, and equipment. As per the International Health Regulations, WHO is empowered to declare a public health emergency of international concern, as it did on January 30 regarding COVID-19 (https://bit.ly/2XvtQkU), and make a “real-time” response.

Did WHO make any missteps? The forthcoming “impartial, independent, comprehensive” review (https://bit.ly/2AHgQzW) of WHO’s response to COVID-19 will reveal these, but WHO’s restraint was predetermined from the get-go by its very decision-making structure, constrained reach (reliance on country reporting and compliance with norms, lack of enforcement mechanisms), and financial dependence on donors operating in their own interest.

Persistent questions remain around China’s delayed information sharing with WHO (https://bit.ly/2Xych3I). That said, once Chinese authorities officially confirmed person-to-person transmission, WHO worked with China in warning the world of this public health emergency of international concern and recommending extraordinary measures to contain it.¹

On another front, under international pressure, China revised its COVID-19 death toll upward (https://cnn.it/2XxEwzG) to correct inaccuracies. By contrast, the belated, gruesome accounting of home and nursing home deaths in the United Kingdom, Italy, France, Spain, and the United States, among other countries, is excused, or at least contextualized within current extenuating circumstances.

Furthermore, countries that heeded WHO’s advice—including Germany, Vietnam, Iceland, Denmark, New Zealand, South Korea, and Finland—benefited from its guidance. (Taiwan, as a non-WHO member, effectively anticipated the situation, but this is a separate case.) In sum, even as the vital learning and renewal process—which all countries should carry out—unfolds, WHO should be allowed to do its work.

Yet one concern trumps all others: WHO is indeed “captured.” WHO’s progressive 1948 constitution established democratic governance via an annual World Health Assembly and a rotating, elected 34-member executive board.² For decades, however, WHO has been impeded from setting policy independently, its agenda setting supplanted by powerful member states, their transnational corporations (TNCs) and philanthropies, and international financial institutions. Since 2010, the World Economic Forum’s Global Redesign Initiative has sought to transform the United Nations (UN), including WHO, into a system of “multi-stakeholder governance” (TNC-, philanthropy-, and big finance–influenced; https://bit.ly/3gV66yv), whereby public monies and UN legitimacy are channeled into private profitmaking endeavors.

Founded amid the early Cold War and decolonization struggles, WHO was always imperfect. Its initial decades were dominated by US-favored campaigns against diseases, such as malaria and yaws, that had ready technical tools (DDT and penicillin) but paid little attention to health-related living conditions or the development of robust health care systems. During a 1960s to 1970s US–USSR collaboration to stamp out smallpox (https://bit.ly/2U4xKPJ), countries of the “Third World” pushed for a reorientation: “Health for All by the Year 2000,” embodied in the 1978 Alma-Ata Declaration (https://bit.ly/3034Ymm). This was WHO’s, and the world’s, best chance at equitably improving health and well-being through a primary health care–based approach—grounded in the right to health, social justice, and a new international economic order—in the context of challenging power asymmetries particularly between North and South.³

But in the 1980s, during a worldwide debt crisis and recession and a neoliberal ideological turn, WHO was bullied by the United Kingdom’s Thatcher and the United States’ Reagan administrations. The latter unilaterally slashed its UN-assessed contributions and then withheld its WHO dues circa 1986 to 1988. These measures were at least partially aimed at reprimanding WHO for its 1977 Essential Medicines program (listing generics), opposed by leading pharmaceutical companies, and its 1981 International Code of Marketing of Breast Milk Substitutes to end unethical marketing practices by infant formula companies. Simultaneously, Alma-Ata, envisioned as a community-driven effort to address underlying causes of disease (e.g., addressing diarrhea through access to clean water and sanitation) within a radical critique of global economic power arrangements, was de-toothed via a Rockefeller Foundation–championed effort to make primary health care “selective” through top-down, narrowly defined interventions.⁴

Meanwhile, the World Bank began upstaging an underfinanced WHO, its loans obliging massive health care system downsizing and privatization across the Global South. Post-2008 austerity policies reverberated northward, too: acclaimed universal health systems were weakened, underfunded, and marketized to great private profit, notably in the United Kingdom and Spain, among the countries worst affected by COVID-19.

With member dues falling or stagnant into the 1990s, WHO was impelled to seek other funding sources. Nowadays, WHO’s budget (approximately $2.4 billion per year [https://bit.ly/2ABiH9e], less than one third [!] of New York–Presbyterian Hospital’s budget [https://bit.ly/2Y0basD]), is more than 80% earmarked by donors for particular activities, affording enormous control to certain high-income countries, corporations, foundations, and public–private partnerships (PPPs; which typically employ technical tools, often produced by these very partnerships, to target individual diseases, while eschewing integrated or health system approaches).

The proliferation of underregulated PPPs, offering unaccountable corporate players decision-making access and unprecedented commercialization opportunities funded by government partners, is a particularly insidious development. In recent years, WHO has been pressured by PPPs, TNCs, and their government partners to, for example, ease up on sugar intake guidelines, recommend massive stockpiling of an inefficacious influenza medication (representing a conflict of interest with Big Pharma), and push the adoption of a noncommunicable disease prevention framework that overlooks regulation of TNCs.⁵

The largest PPPs, the Global Fund and Gavi (the Vaccine Alliance), both heavily supported by the Bill and Melinda Gates Foundation and government contributions, have sidestepped and displaced WHO (which does not even have a vote on the Global Fund’s board), directing billions of public dollars annually into Big Pharma–friendly vaccine purchasing and distribution, and AIDS-, tuberculosis-, and malaria-control efforts that provide lucrative private-sector contracts.⁶

As such, simply stating that WHO has made mistakes and lacks leadership (https://bit.ly/2Mvmd7W) fundamentally misconstrues the situation. Four decades of neoliberal restructuring has led WHO to act precisely as designed: as a broker for powerful interests.

Today, relegitimizing WHO’s power and purview is an urgent matter.⁷ WHO needs adequate dues-based, strings-free financial support to ensure democratic governance, independent agenda setting, and science-based decision-making, based on its constitutional mandate to promote health as a human right. Of course, such a transformation is in direct contestation to the neoliberal onslaught of WHO and the entire UN system. Still, homing in on the societal factors shaping health, from the climate crisis to unsafe work; extractivism (mining, gas and oil, agri-business, etc.); war; forced migration; classist, sexist, transphobic, homophobic, and racist oppression; and prevailing asymmetries of power and wealth—and providing impartial research and advice on the most equitable and effective public health and health care systems according to the principles and practice of universal health justice—will not only engender health equity for all but will also help forestall future pandemics and address the current one.