If, 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 Organization’s 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.
Watching this reassuring spectacle, it is possible to imagine a world in which every nation respects the WHO’s authority, follows its advice and lets it coordinate the flow of information, resources and medical equipment across national boundaries to areas of greatest need.
That is not the world we live in. “The W.H.O. really blew it. For some reason, funded largely by the United States, yet very China centric,” tweeted 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 – even some of the WHO’s 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. “You’ve got a situation where it looks like WHO doesn’t want to exercise its authority,” said David Fidler, a fellow in global health at the Council on Foreign Relations and a regular consultant to the WHO.
Meanwhile, the WHO is desperately struggling to get its 194 member states to actually follow its guidance. The WHO’s leaders are “very frustrated,” said John MacKenzie, a virologist and adviser on the WHO’s emergency committee. “The messages come out loud and clear, and some disregard the warnings. The US largely did, the UK largely did.”
On 11 March, the day Tedros declared the coronavirus a pandemic, he spoke darkly of “alarming levels of inaction” from many countries. Pressed by journalists to name them, Mike Ryan, the usually no-nonsense Irish trauma doctor who heads the WHO’s Covid-19 response, demurred. “You know who you are,” he said, adding that “we don’t criticise our member states in public”.
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 “losing the dressing room”, who can only get their way by charming, grovelling, cajoling and occasionally pleading with the players to do as they say.
The WHO “has been drained of power and resources”, said Richard Horton, editor of the influential medical journal the Lancet. “Its coordinating authority and capacity are weak. Its ability to direct an international response to a life-threatening epidemic is non-existent.”
At the same time, the international order on which the WHO relies is fraying, as aggressive nationalism becomes normalised around the world. “All the previous rules about global norms, public health and understanding of what’s expected in terms of an outbreak has crumbled,” said Lawrence Gostin, director of the WHO Collaborating Center on National and Global Health Law. “None of us know where this is leading.”
The 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 – in the 19th century, at periodic International Sanitary Conferences, countries had standardised quarantine procedures for cholera and yellow fever – but the WHO constitution, adopted in 1948, envisioned a far grander global mission, nothing less than “the attainment by all people of the highest possible levels of health”.
One of the WHO’s 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’t provide the most money, immunise the most people, or invent key technologies such as the bifurcated needle, but it is hard to imagine smallpox having been defeated without it.