In an April 14 press conference, President Donald Trump blamed the World Health Organization for the Covid-19 crisis in the United States and said he would halt its funding “while a review is conducted.” It’s not clear if the president has the authority to do this: Congress approved the United Nations agency’s budget in December 2019, but the Wall Street Journal reports that Trump may be able to reroute the $116 million allocated for 2020 to other global health purposes or organizations or withhold funds for the next fiscal year.
This is not the first time the president has accused the agency of mismanagement. A week earlier, when Trump first threatened to freeze funding, he sniped on Twitter:
The W.H.O. really blew it. For some reason, funded largely by the United States, yet very China centric. We will be giving that a good look. Fortunately I rejected their advice on keeping our borders open to China early on. Why did they give us such a faulty recommendation?— Donald J. Trump (@realDonaldTrump) April 7, 2020
Others in the Trump administration, the GOP, and conservative media have also scolded the WHO. Deborah Birx, the White House coronavirus task force coordinator, and Scott Gottlieb, the former commissioner of the Food and Drug Administration under Trump, criticized its handling of China’s data and transparency. Gottlieb told Face the Nation, “Going forward, the WHO needs to commit to an after-action report that specifically examines what China did or didn’t tell the world and how that stymied the global response to this.”
Senate Republicans, meanwhile, on April 13 announced a plan to investigate the origins of the virus and the global response, including the WHO’s decisions. Senate Homeland Security and Governmental Affairs Committee Chair Ron Johnson told Politico, “We need to know what role WHO might have had in trying to cover this thing up.”
Yet several global health experts Vox spoke to said they believe the agency responded quickly to the Covid-19 outbreak and avoided major missteps. The SARS-CoV-2 virus that causes the disease swept across the globe not because of the WHO’s errors but because of a “very fragmented, chaotic, state-centric response,” according to Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations.
And now, with over 2 million reported cases and 125,000 deaths worldwide, countries “failing in their response have decided WHO is the culprit,” says Ashish Jha, a professor at the Harvard T.H. Chan School of Public Health.
Global health megadonor Bill Gates also swiftly condemned Trump’s promise to cut funding to the agency.
Halting funding for the World Health Organization during a world health crisis is as dangerous as it sounds. Their work is slowing the spread of COVID-19 and if that work is stopped no other organization can replace them. The world needs @WHO now more than ever.— Bill Gates (@BillGates) April 15, 2020
“How can you threaten to withdraw funding from the world’s leading global health agency in the midst of a pandemic, with tens of thousands of people dying?” he tells Vox. “It’s utterly irresponsible.”
Who is WHO?
The World Health Organization works to improve global health in many ways, by improving access to health, strengthening health care systems, and, perhaps most importantly, preventing and responding to medical emergencies. Countries cooperating to control disease actually began earlier than germ theory itself, which started with efforts to coordinate quarantines as far back as 1851. After the world wars, developing an international health organization was one of the first things the new United Nations did, launching the WHO in 1946.
Today, when outbreaks occur, it’s the agency’s job to coordinate information and resources among countries. “WHO functions best when it is sharing information it knows, openly and transparently calling attention to problems of global concern, and setting norms and best practices,” Jha says. During Covid-19, “on those fronts, it’s done a pretty good job.”
Most experts agree there are some legitimate criticisms of how the agency has handled the Covid-19 global health crisis, particularly in how it responded to China’s initial delays and suppression of key information. Other critiques, they say, are less founded. Here are five common questions about the WHO, with answers from the experts we spoke to.
1) Was the WHO slow to declare Covid-19 a public health emergency of international concern and then slow to call the outbreak a pandemic?
In the April 14 briefing, President Trump claimed, “The delays the WHO experienced in declaring a public health emergency cost valuable time — tremendous amounts of time.”
To parse this, it’s helpful to review the timeline. China first reported an unusual cluster of pneumonia cases in Wuhan, China, to the WHO on December 31, 2019. The same day, Taiwan (which is not a WHO member because of objections from China), also emailed the agency, asking for information.
Six days later, the agency alerted the scientific community and global media about the new virus. China did not publicly share the genome sequence of the virus until January 12, delaying WHO’s ability to make tests for the new coronavirus. On January 13, public health officials confirmed the first recorded Covid-19 case outside of China, in Thailand.
In mid-January, the WHO volunteered to send a team into China but was declined. “It wasn’t like WHO was going to be able to bully China into letting a team in. That’s just not how it works,” says Jha, pointing out that Trump would equally be able to say no if the agency wanted to come to New York.
On January 22, just three weeks after first being notified of the virus’s existence, WHO Director-General Tedros Adhanom Ghebreyesus convened an emergency meeting to determine if the outbreak qualified as a public health emergency of international concern (PHEIC), the agency’s term for an “extraordinary event” that requires a coordinated international response — like SARS, H1N1, and Ebola outbreaks in 2014 and 2019. The experts couldn’t agree and decided to meet again. After the director-general traveled to Beijing to meet with Chinese President Xi Jinping in Beijing on January 29, a PHEIC was declared on January 30.
This declaration activated WHO measures to “address travel, trade, quarantine, screening, treatment” as well as national measures in countries that have tied their pandemic response plans to WHO declarations. “I called for WHO to do it a little earlier,” says Gostin, “but it had no impact on the epidemic.” Jha agrees. “I think they could have called it when they initially met, but it wouldn’t have made a big difference,” he says.
On March 11, alarmed by the disease’s spread and governments’ inaction, the director-general announced that Covid-19 could be considered a pandemic. “Ultimately, referring to it as a pandemic is simply a descriptor,” says Adam Kamradt-Scott, a professor of global health at the University of Sydney, an informal classification that didn’t impact WHO obligations or powers.
Declaring a PHEIC at the end of January was what helped initiate states’ preparedness plans and gave the WHO the authority to issue recommendations and guidelines, although not to enforce them. In the March 11 press conference, Tedros was “explicit that he was doing this precisely because he was concerned a number of countries haven’t responded forcefully enough,” Kamradt-Scott explains.
By March, Trump said, “I don’t take responsibility at all” for the slow American response to Covid-19. On April 14, by which time the confirmed US death toll had exceeded 25,000, he reiterated this opinion, saying, “So much death has been caused by their mistakes.”
But, again, all the experts Vox interviewed agreed that the US government’s lack of preparation for Covid-19 was not a result of WHO delays. “Trump has a penchant for rewriting history,” Kamradt-Scott says, “So it’s not surprising to see him blaming the WHO for mistakes ultimately attributable to his own administration.”
ABC News reports US intelligence agencies warned the White House and the Pentagon of the disease as early as November. In January, trade adviser Peter Navarro warned the White House that the novel coronavirus could kill half a million Americans. In February, the US lost valuable weeks failing to develop effective testing. As late as February 27, Trump told a press briefing the virus would “disappear.” The next day, the first American died of Covid-19.
“WHO is not responsible for America not heeding the warnings of its own scientists and security apparatus — for two months,” says Jha. “That’s laughable.”
2) Was the WHO too easy on China?
As early as December, Chinese doctors knew that a new disease was circulating. Dr. Li Wenliang, an ophthalmologist in Wuhan, was detained for “spreading rumors” after trying to warn his colleagues; he later died of Covid-19 at age 33.
By the end of December, Wuhan had nearly three dozen cases of Covid-19, and authorities had closed a market where they thought it was being spread. But the government allowed 5 million people to leave the city for the Lunar New Year. The Chinese government also did not confirm the virus could spread from human to human until January 20. One preprint study suggests that by acting more quickly, China could have reduced its infections by 95 percent.
But when a WHO team visited China in early February, the report its members wrote did not mention these missteps and lack of transparency. Instead, they wrote, “China’s bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic.”
For a time, Trump also repeatedly praised President Xi Jinping’s response, saying in a press briefing on February 7 that he’s handled it “really well” and telling Fox News on February 13 that China was “extremely capable” and handling the outbreak well.
That praise seems unfounded. “The Chinese government allowed the outbreak to evolve into a major epidemic and eventually a global pandemic,” says Huang of CFR. “WHO shouldn’t have downplayed the initial mishandling of the crisis in Wuhan.”
He suggests that although the agency couldn’t have investigated without China’s permission, it could have done more to press the government “to provide more accurate data in a more timely and accurate manner.” (In particular, Chinese officials have made a number of grave errors, including silencing whistleblowers and delaying reporting.)
Gostin agrees that China was not transparent but says that’s not the WHO’s fault. He argues the director-general decided “not to publicly criticize China, believing that smart diplomacy is better to coax cooperation and transparency.”
“In a pandemic, you don’t choose sides,” says Gostin. “Tedros has praised China, and perhaps he shouldn’t have done it, but he also praised Trump, and perhaps he shouldn’t have done that either.”
Overall, WHO has offered little criticism of governments’ responses. “People have fixated on the idea WHO is now in China’s pocket,” says Kamradt-Scott. Back in 2003, after WHO strongly criticized China’s lack of transparency during SARS, checks were placed on the secretariat to prevent future criticisms. Kamradt-Scott says that, fortunately, China has been much more transparent about Covid-19. “It’s much more important to keep China engaged than closing down its correspondence with the international community.”
But the conflict between China and Taiwan has further politicized the global response to Covid-19. The island is not allowed into the WHO, even as an observer, because China claims Taiwan has refused to allow it to participate in multinational organizations as a member state. As the WHO is a UN agency, Kamradt-Scott says, “It’s not in the power of the secretariat to admit Taiwan.” Although China has sometimes allowed Taiwan to participate in the WHO’s annual World Health Assembly, it stopped in 2016 after Taiwan refused to endorse the One China policy.
As coronavirus cases were reported in Taiwan, Quartz reports WHO couldn’t even decide what to call the island. At first, they called it “China, Taiwan,” and then “Taiwan, China” and most recently, “Taipei and environs.” Although Taiwan, which is known for its excellent health care, is only 100 miles away from mainland China, it has only reported 393 cases as of April 14.
In the latest twist, Tedros, the first African director-general of WHO, recently alleged that he had experienced racist attacks and death threats from Taiwan, and accused the Taiwanese government of knowing about them. (Taiwan has denied these claims.) It’s unclear if Taiwan’s reduced access to WHO has had health care consequences.
Tedros, in the same briefing, begged members to put politics aside. ”For now, the focus should be on fighting the virus,” he said. “The United States and China should come together and fight this dangerous enemy.”
3) Should the WHO have recommended travel bans as Covid-19 spread?
On February 2, President Trump closed US borders to non-Americans who’d been in China in the previous two weeks. On March 11, the travel ban was expanded to Europe. Many other countries have since followed suit: Think Global Health, an initiative of the Council on Foreign Relations, has a tally of 96 countries that have restricted travel from China. New Zealand, for example, has been closed to almost all travelers since March 19.
The WHO “actually criticized and disagreed with my travel ban at the time I did it. And they were wrong,” Trump said in a White House media briefing on April 7. It may be too early to determine what effect the US travel bans may have had on transmission: A new study published in Science suggests China’s dramatic lockdown, with stringent travel restrictions between provinces, may have prevented more than 700,000 cases of Covid-19.
But it’s not too early to say that American travel bans didn’t actually stop travel from China. More than 430,000 people traveled from China to over 17 American cities after the virus was discovered but before the ban; another 40,000 people arrived to the US from China after the ban went into place.
Huang explains that one of the main functions of the WHO is to coordinate responses, “But no one listened. What you see basically is a very fragmented, chaotic, state-centric response to the outbreak in terms of trade and travel restrictions.”
Although the WHO has not publicly criticized the American travel ban, it doesn’t recommend travel or trade restrictions during disease outbreaks, both because they often don’t work and because they can make disease response more difficult. Kamradt-Scott recalls firsthand his difficulty in trying to get from Australia to West Africa during the 2014 Ebola outbreak, when all but two commercial airlines had stopped flying there. “It’s not simply that it causes economic damage, but that it impedes responses,” he says.
“The WHO guidance on travel and trade is entirely consistent with previous practice and with science,” says Gostin, who notes that the agency is following the international health regulations that the US has signed but is currently disregarding. “Germs don’t respect borders, so it’s really just deflecting blame,” he says.
Kamradt-Scott, however, is on the fence. He has just completed a literature review, looking at travel and trade restrictions, and his view is that travel bans “may have helped delay the arrival of the virus.” He predicts that eventually Covid-19 research will cause the WHO to revisit some of its guidelines. “It’s rather fraught. It does create economic problems, but if it can help countries by giving them time to prepare, perhaps it can be justified on that ground.”
But, he adds, “Trump implemented travel restrictions but then did nothing to prepare the country, so again, that really comes back to his administration.”
4) Unlike the CDC, the WHO still hasn’t recommended the general public use masks. Should it?
At first, many, including the surgeon general of the US, told the public that masks weren’t necessary and that health care workers needed the scarce supplies. People were told they wouldn’t be able to properly fit them, although several studies suggest that even a homemade mask is better than no mask. Finally, in mid-March, both the CDC and the WHO recommended wearing masks if you are sick.
Today, the CDC is recommending everyone wear a mask when out in public, while the WHO is standing by its recommendation to only wear one if sick or caring for someone else who is sick. “There is no specific evidence to suggest that the wearing of masks by the mass population has any potential benefit,” said Mike Ryan, the head of the WHO health emergencies team. Hong Kong health officials disagree; they have recommended everyone wear masks and say it has helped control the spread of Covid-19.
Because this is a new virus, Gostin says, “Everyone has to operate in circumstances of scientific uncertainty. We have to do the best we can with the knowledge we have.” But new information is coming out every week about the virus’s transmissibility, including one notable report in early April that it can be aerosolized just by breathing and talking. (At this point, he, too, thinks widespread mask use is justified.)
For now, the best we have are educated opinions — no one yet has definitive data on SARS-CoV-2 transmission rates and mask-wearing.
5) Does the US give the WHO too much money?
“[WHO] called it wrong. They call it wrong. They really, they missed the call,” President Trump said, referring to WHO’s declaring a pandemic during a press briefing at the White House on April 7. As a result, on April 14, he declared a hold on WHO funding.
The agency gets money in two-year cycles. The US is currently its largest contributor, giving a total of $929 million (including voluntary donations and membership fees) in 2018 and 2019. The Trump administration has also, however, reduced the next round of American contributions to less than $58 million in its most recent budget proposal for fiscal year 2021.
Under the UN system, countries are expected to contribute a certain amount based on their population size and GDP. Because the US is one of the largest economies in the world, its assessed contributions were large in the 1980s, when the agency froze membership dues in real dollar terms, increasing only due to inflation and exchange rates. “It’s always irked some in the US that even though they pay 25 percent of the assessed contributions, they only get one vote,” says Kamradt-Scott. “But the US agreed to that arrangement.”
Regardless, budget shortfalls have been a problem for the agency for decades. After the 2008 recession, it had to cut $1 billion from its budget and disbanded its epidemic and pandemic response department. The agency “has the operational budget equivalent of a tertiary hospital in any high-income country,” Kamradt-Scott says.
The WHO’s 2020-21 budget is $4.8 billion, or $2.4 billion per year. Only around 20 percent of this comes from membership contributions; the rest is voluntary donations. “The problem is those voluntary funds have strings,” says Kamradt-Scott. “They are tied to particular initiatives, which means that even when WHO is confronted with a pandemic, they can’t reallocate funds.”
This is why, on February 5, the WHO asked for an additional $675 million to fund coronavirus responses, although it took two months to reach its goal. For all of its responsibility, the WHO has no teeth; unlike other international organizations, the WHO has no ability to sanction its members and instead has to rely on diplomacy and donations.
After the 2014 Ebola outbreak, an emergency contingency fund was set up in order to allow the WHO to respond early to emergencies, “sending people to ground to help contain problems before they became a bigger crisis,” Kamradt-Scott explains. But the $100 million fund has never reached its target. “Even when a new mechanism has been set up explicitly to deal with this pandemic, it hasn’t received support from member states.”
“We still need, whether you like it or not, an international health agency that can effectively coordinate an international response,” Huang says. “Slashing funding to WHO would actually reduce the US voice in the international agency and allow other countries to play a bigger role in the organization. That is not something that is in the US interest.”
“I’ve never hesitated to constructively criticize the WHO when I think it’s made a mistake,” says Gostin, “But frankly, I’m outraged and embarrassed by what President Trump did.”
Scapegoating doesn’t change where we are now
There will be plenty of time for reviewing the WHO response, and Gostin says there are many possible reforms: He would double the budget and “invest very widely and deeply in health system capacity, particularly in low- and middle-income countries,” as well as giving WHO enforcement powers during a public health emergency. Kamradt-Scott would like to see the WHO enforce data-sharing during clinical trials. Jha would like to improve transparency in spending.
“You have to remember the fundamental problem of WHO is that it is two things in one, and in all the times it matters, those two things come into conflict,” Jha says. “On the one hand, it’s a membership organization,” meaning it doesn’t “usually beat up on their own members.”
“On the other hand,” he says, “It’s the world’s public health agency, so it has an obligation to the global public that goes beyond the interest of its member states.”
But the middle of this crisis is not the best time to be dismantling WHO. “The focus needs to be on the virus itself,” says Rebecca Katz, professor and director of the Center for Global Health Science and Security at Georgetown University Medical Center. “What we need right now is the largest mobilization of public health we’ve ever seen in our lives. We have no answers — we’re building the plane while flying it.”
We need to build capacity for contact tracing, for isolation, and for quarantine. We need to think through infection prevention and control at the same time as dealing with supply chain issues, to ensure we have enough protective personal equipment and critical medications. We need to better understand the virus we’re fighting. We need to find, validate, manufacture, and distribute a vaccine at a scale never seen before. “At this point, WHO is the only organization equipped to handle these challenges,” Katz says.
“If we didn’t have WHO,” Gostin says, “We would have to invent it.”
Lois Parshley is a freelance investigative journalist and the 2019-20 Snedden Chair of Journalism at the University of Alaska Fairbanks. Follow her Covid-19 reporting on Twitter @loisparshley.