As humans we commonly consider ourselves, our beliefs and our work of particular importance. It is not surprising, then, that when we form institutions, those within them seek to promote the institution’s relevance, expand their work and centralise decision-making within their own ‘particularly important’ group. Few want to divest power and resources, let alone put themselves and their colleagues out of a job. This fatal flaw infects all bureaucracies, from local through national and regional to international.
It is unsurprising then that the World Health Organisation (WHO), an international health bureaucracy of over 9,000 staff, a quarter of them in Geneva, should suffer the same problems. The WHO was originally intended primarily to transfer capacity to struggling states emerging from colonialism and address their higher burdens of disease but lower administrative and financial capabilities. This prioritised fundamentals like sanitation, good nutrition and competent health services that had brought long life to people of wealthier countries. Its focus now is more on stocking shelves with manufactured commodities. Its budget, staffing and remit expand as actual country need and infectious disease mortality decline.
While major gaps in underlying health equality remain, and were recently exacerbated by the WHO’s COVID-19 policies, the world is a very different place from 1948 when WHO was formed. Rather than acknowledging progress, however, we are told we are simply in an ‘inter-pandemic period’, and WHO and its partners should be given ever more responsibility and resources to save us from the next hypothetical outbreak (like ‘Disease X‘). Increasingly dependent on ‘specified’ funding from national and private interests heavily invested in profitable biotech fixes rather than the underlying drivers of good health, WHO looks more and more like other public-private partnerships that channel taxpayer money to the priorities of private industry.
Pandemics happen, but a proven natural one of major impact on life expectancy has not happened since pre-antibiotic era Spanish flu over a hundred years ago. We all understand that better nutrition, sewers, potable water, living conditions, antibiotics and modern medicines protect us, yet are told to be ever more fearful of the next outbreak. Covid happened, but overwhelmingly affected the elderly in Europe and the Americas. Moreover, it looks to be, as the US Government now makes clear, almost certainly a laboratory mistake by the very pandemic industry that is promoting WHO’s new approach.
Collaborating on health internationally remains popular, as it should be in a heavily interdependent world. It also makes sense to prepare for severe rare events – most of us buy insurance. But we don’t exaggerate flood risk in order to expand the flood insurance industry, as anything we spend is money taken from our other needs.
Public health is no different. If we were designing a new WHO now, no sane model would base its funding and direction primarily on the interests and advice of those who profit from illness. Rather, these would be based on accurate estimates of localised risks of the big killer diseases. The WHO was once independent of private interests, mostly core-funded, and able to set rational priorities. That WHO is gone.
Over the past 80 years the world has also changed. It makes no sense now to base thousands of health staff in one of the world’s most expensive (and healthiest!) cities, and it makes no sense in a technologically-advancing world to keep centralising control there. The WHO was structured in a time when most mail still went by steamship. It stands increasingly as an anomaly to its mission and to the world in which it works. Would a network of regional bodies tied to their local context not be more responsive and effective than a distant, disconnected and centralised bureaucracy of thousands?
Amidst the broader turmoil roiling the post-1945 international liberal order, the recent US notice of withdrawal from the WHO presents a unique opportunity to re-think the type of international health institution the world needs, how that should operate, where, for what purpose and for how long.
What should be the use-by date of an international institution? In the WHO’s case, either health is getting better as countries build capacity and it should be downsizing. Or health is getting worse, in which case the model has failed and we need something more fit for purpose.
The Trump administration’s actions are an opportunity to re-base international health cooperation on widely recognised standards of ethics and human rights. Countries and populations should be back in control, and those seeking profit from illness should have no role in decision-making. The WHO, at nearly 80 years old, comes from a bygone era, and is increasingly estranged from its world. We can do better. Fundamental change in the way we manage international health cooperation will be painful, but ultimately healthy.
David Bell is a former Scientific and Medical Officer of the World Health Organisation and Director of Global Health Technologies at Global Good Fund.
Ramesh Thakur, a former United Nations Assistant Secretary-General, is Emeritus Professor at the Crawford School of Public Policy, Australian National University.
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