Perspectives on WHO and the COVID-19 Pandemic
Walter Johnson Professor, Department of Neurosurgery Loma Linda University, Loma Linda, CA, USA 2015-19: Lead, Emergency and Essential Surgical Care Programme World Health Organization, Geneva, Switzerland
The World Health Organization (WHO) is the health technical arm of the United Nations (UN), with core functions that include: - providing leadership on crucial health matters, - setting the research agenda for generating and disseminating valuable knowledge, - creating standards and guidelines, articulating ethical and evidence-based policies, - providing technical support to build sustainable health system capacity, - monitoring health situations and assessing health trends.
The World Health Assembly (WHA), comprised of 194 health ministers representing all Member States of the UN, is the governing body that sets the global health agenda and creates mandates for WHO work. This body sets the what, how, how long, and with what means programs are conducted by WHO.
Historically, WHO has been primarily focused on the prevention and treatment of communicable diseases, including the massively successful effort to entirely eradicate smallpox. However, over the past decade, the global epidemiological profile has rapidly changed to where communicable diseases are eclipsed by non-communicable diseases, primarily cancer, heart and cerebrovascular diseases, diabetes and chronic respiratory illnesses. Current global cancer deaths of around 10 million (2018) are predicted to triple to 30 million by 2030, with 75% occurring in low- and middle-income countries (LMICs). This has necessitated a protracted change in WHO priorities and budgets, and occasioned a major paradigm shift which is ongoing.
The entire worldwide population is suffering through a pandemic of the disease COVID-19, which is caused by a novel coronavirus SARS-CoV-2. The global scale of this disease has not been experienced since the Spanish Influenza pandemic of 1918. By the end of May, 2020, over 6 million individuals had contracted this disease and over 370,000 had succumbed.
Since the very early stages of this pandemic, WHO has been actively involved. However, this is a new and therefore unpredictable disease with unknown causative effects on individuals or within populations. During its entire existence, WHO has not encountered anything on this scale or magnitude, but has quickly assumed a global leadership role in aggregating country and global data, directing evidence-based public health initiatives and offering best-practice scenarios for health ministries. However, there is much criticism of the WHO response to this disease, as well as criticism being directed at certain Member States regarding their responses to evidence during the initial outbreak.
Although on a much smaller geographic scale than COVID-19, WHO has received criticism for each prior global outbreak. Severe acute respiratory syndrome (SARS), a viral respiratory illness caused by the SARS-associated coronavirus (SARS-CoV), was first reported in Asia in February, 2003. At that time, only when WHO presented their internally acquired evidence to China, was this outbreak acknowledged. Over the next few months, the illness spread to 26 countries in North America, South America, Europe, and Asia before the SARS global outbreak was fully contained. For the first time, WHO issued travel advisories to assist in the containment of the outbreak, where previously this was left to individual Member States.
According to WHO data, a total of 8,098 people worldwide contracted SARS during the outbreak, of which only 774 died. In the United States (US), only eight people had laboratory evidence of SARS-CoV infection and all these people had been exposed through travel to endemic areas. SARS did not exhibit wide community spread and no one died in the US.
During the H1N1 (swine flu) crisis of 2009, 18,500 deaths in 74 countries were recorded, but far fewer than the large number originally estimated. Although there were mixed reviews, WHO was widely criticized for its overly aggressive stance and crying “Wolf” too quickly; the argument being that an enormous amount of money was spent with resultant widespread public panic for little apparent good reason.
In 2014, during the Ebola outbreak in East Africa, WHO leadership was widely criticized as being an “egregious failure”. This was partly blamed on the consequences of the 2008 global economic collapse where WHO funding was significantly limited. However, the WHO response was so limited that several countries deployed military personnel to assist in containing the outbreak. Over 11,000 individuals lost their lives in this outbreak, primarily in three countries.
This pandemic has been thrust upon new WHO leadership that did not experience SARS, H1N1, or Ebola (although there was a much smaller Ebola outbreak in 2017). Furthermore, many Member States are embracing nationalism, which erodes support of global institutions such as WHO. This forces WHO to face a breakdown in international cooperation that it does not have the capacity to control. Member States are keen to reduce the numbers of patients in their own country, but less concerned about global numbers.
WHO recommendations are simply that – they are not direct mandates, as WHO has no ability to enforce policy. This is reflected in Member States’ wide variances in response to WHO recommendations to quarantine and contain vulnerable populations, limit public exposure, as well as track and trace all known cases. Member States should also share all relevant data and resources. But Member States have mostly ignored WHO recommendations, giving them lip service and charting their own way. Consider the differences between Singapore, South Korea, Germany and Sweden, or within the US, California vs New York. The consequences of COVID19 are still emerging from Sub-Saharan Africa.
Since 1948, the WHO Director-General (D-G) has demonstrated varying degrees of political sensitivities. The third D-G, Dr Halfdan T Mahler of Denmark (D-G 1973-1988), an outspoken supporter of surgical care, preferred the notion that results achieved eclipsed the limitations imposed by politics. Similarly, Dr Gro Harlem Brundtland, prior Prime Minister of Norway and D-G from 1998-2003, strongly believed that international organizations should lead when necessary, rather than following the preferences of powerful nations. “If the job is to direct and coordinate global health, it’s not a question of what one or several governments ask you to do,” she said, “We are working for humanity.” This attitude has not always been reflected by WHO leadership; D-Gs have chosen their own style and comfort level in dealing with stronger Member
States. This can be fraught with difficulty as these stronger nations are precisely the ones that provide the most significant funding to WHO.
As stated earlier, the WHA is the governing body of WHO. The WHA individuals elect the D-G, frequently in blocs of Member States. When Dr Tedros Adhanom Ghebreyesus of Ethiopia was elected in July 2017, there were three finalist candidates: one from UK supported by most Commonwealth nations and US; one from Pakistan supported by the Organization of Islamic Cooperation (55 nations); and Dr Tedros, supported by the African Union (54 nations) and Asian countries, including China and India. Not surprisingly, China, with its One Belt, One Road initiative, wields significant influence with many African and Asian Member States. For these reasons, WHO D-G and employees,will not, under any circumstance, criticize Member States or their leaders for responses to and effectiveness in disease outbreaks or other public health issues. In addition, Dr Tedros is up for election at the WHA in May 2022, and will likely be actively seeking the support of each Member State during the 2021-2022 year, especially those nations that supported his initial election.
Finally, there are many issues related to WHO that are uniquely challenging. The US, which provides 22% of WHO budget, just announced it is severing all ties with WHO and removing all funding. This is partly due to WHO’s perceived soft stance towards China during this pandemic and the current political, economic, and technology wars between US and China. This is also due to wide policy mismatches, such as WHO’s emphasis on Universal Health Coverage (UHC), which runs counter to US priority of global health security, plus the US does not embrace UHC as a national health policy. UHC is one part of WHO’s triple billion goal by 2023 and the underpinning of nearly all the UN’s Sustainable Development Goal 3 health targets. Among other issues is the WHO/US clash on abortion and reproductive health policy, and the looming quagmire of Taiwan’s inclusion in the UN and WHO, even with observer status, which Taiwan enjoyed briefly until 2016 under the title “Chinese Taipei.”
However, given the significant challenges, even failures of WHO at times, there are also overwhelming successes. Retaining a global health body that convenes Member States, fulfills its stated core functions, and provides global leadership during health crises, is critical to global health. No other body or Member State will provide this coordinated leadership and no other body will bring together 194 Ministers of Health into an international forum to set global health priorities and agendas. Aside from some “developed” Member States, most LMICs look to WHO specifically for those core functions and rely on WHO at all levels of the organization, but particularly the Country Office, which is viewed as an essential ally of the local health ministry. WHO provides a critical and essential resource for global health and this world would be far less healthy or stable without WHO. This critical function cannot safely be overlooked even during the current political mudslinging.
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