Gostin LO. COVID-19 Reveals Urgent Need to Strengthen the World Health Organization. JAMA Health Forum. Published online April 30, 2020. doi:10.1001/jamahealthforum.2020.0559
From the time China reported a novel coronavirus to the World Health Organization (WHO) on December 31, 2019, it took barely 4 months to become a pandemic, killing hundreds of thousands, and growing daily. It is now clear that the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had been circulating in Wuhan, China, for weeks before China reported it to the WHO, and that authorities hid information. China maintained SARS-CoV-2 was not readily transmissible between humans. The WHO published China’s data, but without independently verifying their accuracy.
President Trump subsequently blamed the WHO for its slow and “China-centric” response. On April 14, 2020, he announced a suspension of US voluntary contributions to the agency.
Although the WHO was unable to verify the Chinese data, it was proactive, including widely sharing the genomic sequencing of the virus with international scientists. On January 30, 2020, the WHO declared coronavirus disease 2019 (COVID-19) a global health emergency, urging rigorous containment including testing, contract tracing, and quarantine. Broad criticism of the organization is unfounded, and is particularly damaging because the pandemic is poised to deeply affect sub-Saharan Africa. That said, legitimate concerns about the WHO include its reluctance to insist China allow a robust WHO team on the ground and its praising of China’s transparency.
The crisis now unfolding could also become a historic opportunity to strengthen the WHO. Reforms must start with recognizing the global public good achieved by the WHO.
Formed in 1948 as the first United Nations (UN) specialized agency, the WHO has helped protect humanity from global health threats. Its early work prioritized tuberculosis and malaria, as well as sanitation, maternal and child health, and nutrition. The WHO’s most celebrated achievement was eradicating smallpox in 1980. Today, the WHO and its partners are on the verge of eradicating wild-type polio, now confined to Afghanistan and Pakistan. After eliminating malaria from more than 2 dozen countries during the 1950s, the organization now aims to reduce 90% of malaria cases and related deaths by 2030.
The WHO has responded to public health emergencies of international concern, authorized under the International Health Regulations (IHR) in 2005, including the 2009 pandemic influenza A(H1N1) virus, polio in 2014, Zika in 2014, Ebola in 2014 and 2018, and COVID-19 in 2020. After the West African Ebola epidemic, the agency revamped its response capacity, forming a Health Emergencies Program and launching a health emergencies fund.
Beyond infectious diseases, the WHO monitors global health trends, conducts research, sets standards, and provides technical support. The agency’s work ranges from noncommunicable diseases, nutrition and obesity, to mental health, road safety, and antimicrobial resistance. Importantly, the WHO provides relief for the hundreds of millions who suffer from extreme poverty. Responding to the UN’s Sustainable Development Goals, the WHO devised a 5-year “triple billion” strategic plan: 1 billion more people benefitting from universal health coverage, 1 billion more people protected from health emergencies, and 1 billion more people with improved overall health.
The WHO has achieved so much even with paltry funding. Out of the COVID-19 pandemic, the WHO could be reimagined as a stronger, more responsive international agency. Among the most crucial reforms are funding, member state compliance with norms, and political support.
The WHO is chronically underfunded, given its comprehensive global mandate. Its biennial 2020-2021 budget is $4.8 billion—similar to a large US hospital, and about $2 billion less than the US Centers for Disease Control and Prevention’s annual budget.
Sustainable investments in the WHO would more than pay for themselves. Consider that the COVID-19 stimulus packages in the US cost trillions, compared with scant funding devoted to global health. Investments in any aspect of the WHO’s portfolio would reap returns in healthy lives and economic gains through increased productivity. Even raising the agency’s budget in line with the US Centers for Disease Control and Prevention’s budget would more than double the WHO’s budget. The WHO should undertake a transparent planning process to estimate realistic budgets needed to achieve tangible health benefits.
Not only is the WHO’s budget too low compared with its global mandate, but it also is too reliant on voluntary funds. Not even $1 billion of the WHO’s 2018-2019 budget came from member states’ mandatory assessments, with the rest from voluntary, earmarked funding. The WHO’s budget would be more predictable if a higher percentage came from mandatory assessments. Countries could commit to mandatory assessments to cover half the organization’s budget.
The WHO suffers weaknesses common for international organizations: limited compliance with norms and few tools to enforce norms. Under the legally binding IHR, member states agreed to develop core health capacities to detect and respond to public health emergencies. The IHR entered into force in 2007, yet compliance remains spotty.
The WHO has tools to improve compliance, though at a political risk. Under article 7 of the WHO’s constitution, member states that fail to meet obligations may have their voting privileges or other services suspended. The WHO director-general could seek World Health Assembly approval to invoke article 7 in cases of severe noncompliance. New compliance-enhancing tools might include WHO funding to incentivize member states to meet IHR duties, especially health system capacities. As a post-Ebola commission proposed, the International Monetary Fund could incorporate national preparedness into its macroeconomic assessments, which affect countries’ access to capital. Reform of the IHR could specify that noncompliance could amount to an article 7 violation. And countries could bring cases of unjustified trade restrictions to the World Trade Organization. Civil society could also monitor member state compliance and issue shadow reports, much like on human rights compliance.
The WHO relies on governments for funding and support. The agency should not have praised China’s transparency when it suppressed information on community transmission. Yet the WHO’s dilemma is clear: it relies on member state cooperation, including access to a member state’s territory to get the WHO’s experts on the ground.
The WHO director-general must have freedom to act in the best interest of public health and science without political interference. Solutions are difficult but must be found.
Although high-income countries used their own resources to respond to COVID-19, the pandemic is poised to affect low- and middle-income countries. The WHO’s historic value-added has been primarily in low- and middle-income countries. The location of the WHO headquarters in Geneva, Switzerland, the epitome of a rich country in the heart of Europe, sends the wrong signal. If its headquarters were moved to sub-Saharan Africa, the WHO would be in a better position to respond rapidly where its technical assistance is needed most. Whatever the challenges, moving its headquarters to Africa would be a powerful symbol of the WHO’s commitment to the world’s poorest communities, making the organization seem less aloof and more relevant in the modern world.
Governments have the WHO they deserve, an agency hobbled by chronic underfunding and weak political backing. It is little wonder that successive WHO directors-general have found it difficult to speak truth to power. With the devastating toll COVID-19 is taking across the world, it is past time to give the people of the world the WHO they deserve.
Corresponding Author: Lawrence O. Gostin, JD, Georgetown University Law Center, 600 New Jersey Ave NW, McDonough 568, Washington, DC 20001 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Lawrence O. Gostin, JD Lawrence O. Gostin, JD, is University Professor, the Linda D. and Timothy J. O'Neill Professor of Global Health Law, Faculty Director of the O'Neill Institute for National and Global Health Law at Georgetown University Law Center in Washington...