Why the World Health Organization’s Response to COVID-19 Is Crucial to the Future of Public Health

It’s usually not a good sign for humanity when the World Health Organization is in the news. There may not be a better indicator of how 2020 is shaping up than the weeks-long flurry of headlines featuring the U.N. agency tasked with coordinating the global response to infectious disease outbreaks.

Since originating in China in December, the COVID-19 virus has infected more than 820,000 and killed over 40,000 around the world, as of Tuesday, while crippling the global economy. WHO has held regular briefings to share information about the outbreak and the best practices for how to respond to it. Though Director-General Tedros Adhanom Ghebreyesus has been criticized for his praise of China, he’s at times shown a willingness to call out bad behavior from other global superpowers, such as when he lamented the “level of stigma we are observing” in a not-so-subtle slight at the racist language President Trump has used to describe the virus. “There is a common enemy on this planet,” Tedros said in March. “We need to fight in unison.”

Considering its tepid response to the West African Ebola outbreak in 2014, an across-the-board failure that many public health experts feel marked a low point of the organization’s 70-year history, WHO’s proactive approach to the coronavirus outbreak has been encouraging. “The World Health Organization has done exactly what we’ve designed it to do — no more, no less,” Kelley Lee, the director of global health studies at Canada’s Simon Fraser University, who has been studying WHO since the 1990s, tells Rolling Stone. “It has kept us informed. It has mobilized scientists and coordinated data and research. It has collected the best evidence and tried to put forward very clear guidance about what should be done. The big question is whether we’ve given it enough authority and resources to act the way we want it to act.”

Standing in the way of WHO receiving those resources are its more powerful member nations, particularly the United States. Despite the outbreak, the Trump administration proposed cutting funding to the organization and refused to adopt WHO’s COVID-19 testing kits for use in the U.S. (Trump falsely claimed the effective tests are “bad.”) The president isn’t likely to come around to the idea of investing in a more robust global public health apparatus, regardless of how much havoc the coronavirus is yet to wreak. But the next president might. So might the rest of the world. This is why it’s so imperative for WHO to demonstrate its competency in the coming months. COVID-19 won’t be the last pandemic to befall the developed world, and a well-funded, well-run WHO may be the best defense against future catastrophes. Unfortunately, it’s been a long time since “well-funded” and “well-run” were used to describe the agency managing global public health, which is more crucial than ever in an increasingly globalized world.

Founded in 1948, the World Health Organization was one of several special agencies established by the United Nations in the years following World War II to coordinate global policy on a variety of issues (others include the International Monetary Fund and the World Bank Group). Throughout its history, WHO has been at the forefront of the global fight against infectious diseases, its signature accomplishment coming in 1980 when it announced smallpox had been eradicated from the planet. It has also been instrumental in the near-eradication of polio, and has received plaudits for its work to combat outbreaks like SARS and the Zika virus.

But the bulk of WHO’s work consists of data gathering, defining terminology, creating protocols, and other vital but largely thankless coordinating functions. “When you go to receive health care, you want to know everyone is talking about the same thing when they are diagnosing a particular illness,” Lee explains. “That happens because WHO coordinated all of the different countries to agree that we’re going to call this disease this, and this is what it’s going to look like, and these are the diagnostics. There’s a lot of important technical work happening behind the scenes that enables health systems to work.”

Though its work may seem uncontroversial, WHO has been under near-constant scrutiny for most of its existence. Critics say it has long been mired in — if not paralyzed by — structural and staffing issues, and it has a reputation as a cloistered institution filled with technicians who lack the political chops necessary to manage its standing among governments. “There was always this attitude of, ‘We’re the World Health Organization. We know best. We’ll take care of it and let you know at the end,’” says Ashish Jha, director of the Harvard Global Health Institute. “I personally think that’s a terrible way to run an organization when you’re trying to build confidence.”

WHO’s issues rest in the conflict between its broad mission to serve the world’s public health needs and the political realities attached to how the organization is funded: by its 194 member states and other outside actors who control how the vast majority of WHO’s resources are allocated. 

WHO’s budget is made up of two types of contributions: assessed and voluntary. Assessed contributions come in the form of dues from its member states. WHO is free to use this money however it chooses. Voluntary contributions come from a mix of additional money kicked in by some of the more powerful member states, NGOs, private interests, and philanthropic organizations like the Carter Center, Bloomberg Philanthropies, and the Bill & Melinda Gates Foundation, traditionally one of WHO’s largest donors.

But voluntary contributions are typically earmarked for specific purposes dictated by the donors and which may or may not align with the world’s most pressing public health needs. For example, the Gates Foundation’s primary concern is polio eradication. In 2018, it volunteered just under $100 million to WHO, nearly double the amount offered up by any nation except the U.S., which gave just over $132 million in specified voluntary funding. This means that a large portion of WHO’s budget is funneled toward polio eradication, an issue some argue receives an undue amount of the organization’s attention.

“There’s a question of, for all of the resources that are being put into polio, given how few cases are actually out there, is this a disproportionate response?” says Jeremy Youde, an expert on global health governance and dean of the College of Liberal Arts at the University of Minnesota, Duluth. “Could we be putting this money toward something else that affects more people, like measles or malaria? It gets to the question about prioritization. It’s a lot of money for what seems to some like a relatively minor payoff.”

Voluntary contributions like the tens of millions it receives from the Gates Foundation make up the vast majority of WHO’s relatively sparse resources. WHO’s proposed two-year budget for 2020-2021 is just over $4.8 billion (for perspective, the U.S. Centers for Disease Control’s proposed budget for 2021 alone is just over $7 billion). Around 80 percent of that comes from voluntary donations, meaning the organization has control over about only 20 percent of its resources. WHO has fought to little avail to persuade its member states to ramp up their assessed contributions, or give it more discretion over how it allocates voluntary contributions. The organization has been hamstrung by this inflexibility for years. (WHO did not respond to a request for comment from Rolling Stone.)

“It’s an organization with 194 masters, and those 194 masters don’t necessarily have the same agenda,” Youde says. “It’s trying to balance all these competing interests, and unless those member states are willing to give the World Health Organization more autonomy to flex its muscles, it’s kind of trapped, even though it’s expected to have all this power.”

One of the reasons WHO’s funders aren’t willing to give it more flexibility is because they don’t trust it. Bureaucratic red tape has hampered its ability to respond nimbly to public health crises, and it has long been criticized for favoring the agendas of its more powerful donors. Following the H1N1 outbreak in 2009, WHO was accused of tailoring its response to align with pharmaceutical interests. Though the public health experts interviewed by Rolling Stone tamped down the idea that its motives may have been corrupt, the appearance of impropriety is inevitable given the degree to which donors have their heels on the organization’s neck. “It’s a circular thing,” Lee explains. “You underfund an organization like the World Health Organization and then it struggles to do the things you want it to do. So it doesn’t perform well and you say, ‘Oh, I’m not going to give money to this organization.'”

Considering its byzantine structure and limited resourcing, WHO has essentially been “set up to fail,” as Lee puts it. It operates within a rat’s nest of bureaucracy, competing interests, and an overlarge mandate to rid the world of disease. “On one hand it’s expected to be a world-class public health agency, but at the same time it’s expected to manage the complicated global politics that emerge on health issues,” says Steven Hoffman, director of the Global Strategy Lab and a professor of Global Health, Law, and Political Science at York University in Canada. “The organization struggled with that duality.”

WHO’s weaknesses proved disastrous during the 2014 Ebola outbreak, which ultimately claimed more than 10,000 lives across West Africa. As Jha notes, the organization “made a series of critical mistakes” in responding to the outbreak, most notably waiting five months after initial cases were confirmed to declare it a Public Health Emergency of International Concern. WHO was savaged for the delay, which critics say was caused by a mix of bureaucratic paralysis, lack of emergency response preparedness, and a desire not to upset the affected nations, which stood to suffer economically from the designation. “Even though they were poor West African countries, [WHO] was afraid to interfere too much or declare a public health emergency because it thought those governments wouldn’t want it,” says Charles Clift, a senior consulting fellow at the Chatham House’s Global Health Programme who worked for WHO from 2004 to 2006. “It was a weak-kneed approach.”

The failure marked a low-point for WHO’s standing worldwide. “It was a crisis, and almost an existential threat,” Jha says. “The World Health Organization does a lot of different things, but if you can’t coordinate and be effective in response to a multinational infectious disease outbreak in low-income countries, then what do you exist for? It’s the core of your mission.”

Committees were assembled to figure out what went wrong and how to fix it. A Health Emergencies Programme was established, but the organization’s priorities going forward remained unclear. “The question I’ve always asked about the World Health Organization is about its identity crisis,” Jha says. “Is it a membership organization or is it the world’s leading public health agency? Eighty percent of the time they require the same actions, but in the most important moments, the 20 percent, WHO has to sometimes choose if it’s going to serve its members or be a representative of the world’s public health needs.”

The fallout from the botched Ebola response paved the way for the election of Tedros in 2017. Unlike Margaret Chan, who led WHO from 2006 to 2017, Tedros — who is both the first African-born director-general and the first director-general to not be a medical doctor — came from a political background, having served as the foreign minister of Ethiopia. “The World Health Organization only has so many levers available to it to influence state behavior,” Youde says. “It can’t force a state to implement policies. But having someone who has that sort of understanding of the politics is really important, because we can’t ever really separate politics and economics from public health.”

Tedros has used his political acumen to reach out to governments and cast public health within the framework of their economic needs. He’s made mistakes — like naming the late Zimbabwean president Robert Mugabe a goodwill ambassador, an appointment he was forced to rescind — but he’s worked to revamp some of WHO’s structural and staffing issues while increasing the organization’s transparency. Crucially, he’s promoted sharing the burden of some of WHO’s responsibilities with other global public health organizations and encouraged governments to invest in their own health systems. “The World Health Organization used to be competing for resources against other actors in the global health system, but now it’s trying to be a steward of the system as a whole,” says Hoffman, who describes Tedros as a “global-health political megaphone about what governments need to do and the type of investments they need to make.”

Though Tedros has received high marks for his leadership during the coronavirus outbreak, he’s drawn criticism for how he’s handled its central political challenge: dealing with China. Unlike the Ebola outbreak, which originated in West Africa, the original epicenter of COVID-19 was in a global superpower notorious for lacking transparency and abusing human rights. Almost immediately, Tedros traveled to Beijing, and he has since heaped effusive praise on China’s response to the outbreak despite its initial reticence to turn over data, as well as the fact that some of the extreme measures the nation later took to contain the virus resulted in human rights abuses. WHO’s deference to China has also renewed criticism that Taiwan — one of the few nations to effectively combat the coronavirus — is not a U.N. member state, and thus not a WHO member state.

“It’s a balancing act,” Jha says. “I don’t know anybody in the world who knows how to take on China. WHO has to work within a certain set of confines. It’s easy to say he should have been a little bit tougher, but it’s an incredibly tight rope that he’s walking. If he had been aggressive with China and criticized them for not being more open in December, China could have just said buzz off and we’ll give you nothing. Would the world be better off it that happened? I don’t think so.”

Though praising China in order to get it to cooperate may have helped WHO better understand how to tackle the coronavirus around the world, failing to call it out for its human rights abuses could have long-term consequences. “I worry that this could set new norms about what countries are allowed to do both in this outbreak and in future emergency situations,” says Hoffman, who also directs the WHO Collaborating Centre on Global Governance of Antimicrobial Resistance. “In some respects, with China taking these extraordinary measures and WHO praising them, we now live in a new world when it comes to human rights in health emergencies.”

The question of how to deal with China is a prime example of WHO’s larger dilemma of reconciling the gap between the individual interests of 194 nations and the world’s public health needs, human rights standards, and everything else WHO is mandated to uphold. Though many feel Tedros has honed WHO’s focus and made strides in rehabilitating its reputation, the organization’s ability to carry out its mission will always be dependent on how long a leash its member states allow it, both in terms of raw funding and the freedom to use that funding as it sees fit. The unprecedented scale of the coronavirus outbreak could lead to some flexibility, or at least that’s the hope.

“I hope these kinds of events show why we need to make investments in public health,” Hoffman says. “Not just during pandemics but between them and in advance of the next inevitable one. But there’s really only one country that’s been a roadblock to increasing WHO’s mandatory contributions, and that’s the United States.”

Hoffman points to the Trump administration’s widespread cuts to public health, including its funding of WHO. On February 10th, as COVID-19 was spreading throughout the U.S., the administration released a 2021 budget proposal that included a 53 percent cut to WHO’s funding. “Not seeing the value of the World Health Organization highlights how unprepared the United States was for a pandemic,” he says. “Americans are only as safe as others around the world given how connected Americans are with the global economy and how many people travel to the U.S. every day. Any government talking about reducing WHO’s budget in a time of globalization and unprecedented global-health security threats is just not recognizing the importance of having a public health infrastructure generally, nor the specific value that WHO brings to the table.”

Whether Trump likes it or not, the world is becoming more and more globalized, which means it makes less and less sense to abstain from investing in global alliances or organizations, from NATO to WHO. This is especially true regarding public health. The spread of COVID-19 has made it clear that it’s in America’s best interests to ensure less-developed nations have the infrastructure necessary to prevent and combat the spread of infectious diseases, which will inevitably find their way into the U.S. if they’re not contained. Trump’s “America First” rejection of globalism is quite literally putting American lives at risk.

“Globalization is part of what has made modern political and economic systems possible, but it’s also increased the risk that we face,” Youde explains. “It’s easier for people and goods to cross borders, but it also increases the chances these infectious diseases are going to spread and that we’re going to see these outbreaks. At the same time, globalization gives us the tools we need to try to combat this. If we have an organization that has those resources, it’s going to be really well equipped to identify these outbreaks early and to try to make sure information is being shared among governments, so we’re less likely to be surprised — or if something does pop up, we’ll be able to respond quickly.”

Superpowers like the U.S., China, and Russia aren’t exactly tripping over themselves to volunteer some of their sovereignty in service of fostering a coordinated global effort to combat infectious diseases, but if anything is going to spur more investment in organizations like WHO, it’s the devastation caused by COVID-19, especially considering its economic impact. “I’m hoping that when all is said and done with the coronavirus, there will be a broader international conversation about WHO’s performance and mission, and how global public health needs a lot of resources when something like this happens,” Jha says. “The effect on the world’s economy is going to end up being worth trillions of dollars.”

Whether it’s the economic impact, the death toll, or the fundamental disruption of life as we know it, something has to inspire consideration of what Lee calls these “profound” questions about how we’re governing the world. Next time the virus could easily be more deadly, and given the scale at which the world has been globalized there will almost certainly be a next time. “What’s it going to take for people to wake up?” she says. “I used to say it would take a really big outbreak or catastrophe. Now it’s here. We’ve got it. If we can learn from this one we’ll be so much better equipped for the next one. But people just don’t want to face those questions.”

This post has been updated to reflect that Taiwan’s WHO member status is contingent upon its U.N. member status.