“The W.H.O. really blew it,” President Donald Trump tweeted on April 7, referring to the World Health Organization. “For some reason, funded largely by the United States, yet very China centric. We will be giving that a good look.”
Trump’s tweet, coincidentally, came on World Health Day, which honors health care workers around the world and celebrates the 1948 founding of the World Health Organization. The global health institution was created in a post-World War II world, based on the belief the planet had to work together to fight diseases and promote the health of all citizens.
And when a pandemic happens, it’s obvious why the world needs an institution to help coordinate resources and distribute information.
But the WHO has come under pressure for its handling of the coronavirus, including whether it was too slow to declare a global health emergency and too generous in its praise of China for its handling of the outbreak.
Whether or how the WHO misstepped is up for debate. But President Trump, at least, has decided it failed to do enough, and on Friday, he announced his intention to withdraw from the agency completely.
Whether Trump has the power to do that unilaterally is still unclear, but if the US does pull out, it could cripple the organization. The WHO is made up of member states, meaning it is only as effective as the countries that make up that body, and that definitely includes superpowers like the United States. As Kelley Lee, research chair in global health governance at Simon Fraser University in British Columbia, Canada, said in April, you can’t blame the WHO for failing to act if you don’t empower it to begin with.
“To say, ‘WHO should do this, WHO should do that.’ Well, WHO is the member states,” Lee said. “So if you want WHO to do something, then the member states have to get together and say: ‘Do this.’”
Lee studied WHO reform efforts in the 1990s, published a book on the organization, co-established the WHO Collaborating Centre on Global Change and Health, and has chaired the WHO Resource Group on Globalization, Trade and Health.
I spoke to her in April — after Trump threatened to withdraw funding to the agency — to get a better understanding of the WHO’s mission, why the WHO is facing criticism, how the organization got to this point — and, whether and how the World Health Organization’s shortcomings can be fixed before the next pandemic hits.
This interview has been condensed and edited for clarity.
This is a very basic question, but what exactly is the World Health Organization?
In a nutshell, it’s the United Nations’s specialized agency for health. So the WHO is the coordinating body for international cooperation in the health sphere.
It was created in 1948, after the Second World War. It had predecessors; it was formed by bringing together some of the regional bodies that existed. There was a League of Nations organization for health that didn’t go anywhere because the United States didn’t join, so they tried to make it more open and more member-state-oriented.
And what is the WHO’s role — or should be its role?
It was created to balance those needs at the time, which were post-war outbreaks and trying to respond to humanitarian needs. Over time, it’s evolved in different ways into an organization that provides both what they call “normative functions” — providing guidelines and technical advice, collecting data, statistics, and so on. And then, I think increasingly member states wanted it to take a more active role in advocating for specific health issues. So it got involved in things like Health for All and all sorts of campaigns.
But essentially, if you look at the WHO’s constitution, it is a member-state organization. It doesn’t have independent authority to do what it likes. The World Health Assembly meets every year. And that is sort of the legislative body of WHO, and the secretariat carries out what is decided upon. It doesn’t mean [they don’t] have any powers, the secretariat and the director-general, but it really has to go through all the member states.
So the way I describe WHO is it’s the ultimate committee-designed organization. You know, when you try and do something by committee, it can end up a bit of a mess.
The other way I describe the WHO is like if you go into a restaurant, it’s got everything on the menu. It’s one of those Gordon Ramsay moments where, “You need to reduce this menu, you can’t do everything.” And I think WHO has been like that because it’s had to respond to 194 countries. So it has everything to do with health. And I don’t think that’s tenable for any organization, especially when you have frozen resources. And so you’re spread more and more thin, and you’re trying to do everything.
That’s the perfect overview, and this idea that it’s a restaurant with everything being on the menu is an interesting one. Is that because, after the WHO was founded in 1948, it just kept adding new priorities, and didn’t take anything off the menu? Why does it just have such a massive mandate?
It is a very cumbersome organization, lots of different parts, the way it’s structured, with headquarters and then regional offices and country offices. But I think it really reflects the starting point in the organization, its constitution. And if you look at the definition of health, it’s a very broad one. It’s not just the absence of disease, but it’s all of these things like well-being and so on. That interpretation, over time, has led to everything under the sun [being placed] under what health is.
In a way, it’s right. It’s that tension between a disease focus and a more clinical look at what health is, and broader, social determinants of health — the environment, education, and so on. So there’s always been that tension and almost philosophy about what health is, and what creates good health and well-being.
And you see this across the different countries even: the US versus some of the European countries. That’s all played out at WHO. WHO needs to accommodate all of these kind of philosophies about what health is and it’s responding to both high-income countries and low-income countries. Trying to be everything to everyone, and that’s what the constitution laid out.
So from the beginning, I think its design was almost impossible to fulfill, unless you had the right resources. Priority setting has always been a problem, and it’s been an ongoing effort to reform the organization to be better at priority setting; when everything’s a priority, nothing’s a priority.
I’ve been in so many reform meetings where, it’s like, “What do we cut? Mental health? Or do we cut road traffic accidents?” Everything is important. It’s a Sophie’s Choice situation where, “Which child do you give away?”
Obviously when there’s an outbreak like this, of course, this is everybody’s immediate priority. But these other issues are not less important, just because they’re chronic or long-term. So how does the organization choose where to put its limited resources? And that’s been a real struggle.
With so many priorities, was the WHO caught in a similar situation where it had so many priorities, that it also wasn’t really prepared or had the resources to deal with a pandemic?
So, WHO doesn’t have any resources to be the action on the ground. It’s always been very much an advisory body, recommending what a country should do. It doesn’t have the UNICEF [United Nations Children’s Fund] mode of operation where it can go in and vaccinate children, for example.
WHO has never done that, that’s not what its role is supposed to be, to get into countries and be boots on the ground. And people probably wanted that to happen. “Oh, why isn’t WHO sending in people into Wuhan?” That was never its role. Its role was to do intelligence-gathering, and then alert countries, and countries are the ones that act. So there’s that.
The other thing is, to say, “WHO should do this, WHO should do that.” Well, WHO is the member states. So if you want WHO to do something, then the member-states have to get together and say, “Do this.”
And that is the other problem. Countries are very divided about what WHO should do. So there’s a lot of difference of opinion. Some people say some countries get their way more than others. So there’s this kind of [debate] being played out: What is it that WHO should do? Countries are not agreeing, so then WHO ends up doing everything.
So it sounds like part of the problem is not just WHO’s mandate, but the dynamic of member states, which is a reflection of how the world operates. I imagine member states who have more leverage on the international stage, or who give more funds, have a lot to do with shaping that agenda. Given the current debate, I’m specifically thinking of the United States, or China.
It’s ironic that the US is accusing WHO of being China-centric, when actually for decades, it’s been accused of being very US-centric, if anything. So it’s kind of interesting how it’s playing out, for sure.
The organization likes to be seen as scientific and medical, and that it’s trying to keep politics out. What I’ve written in the past is that it’s inherently political. But the thing is, you want to have good politics, you want to have all countries being able to express their views. Yes, we all have different interests. But have a fair process, allocating resources or priorities accordingly, not having one or certain parties dominate.
When you have bad politics, when there’s unfairness and there’s a lack of transparency and accountability, that’s when problems happen. It’s not like we can take politics out of WHO. But what we want to do is take bad politics out of WHO. And that’s the challenge.
And for an organization where the funding is so skewed toward voluntary contributions, this is the problem. “Whoever pays the piper, plays the tune” type thing. You have all these vested interests buying, basically, what WHO does. It’s a very difficult situation.
But I imagine this difficult situation has not happened in a year, or two. Can you point to a period in time when these politics really began to interfere in WHO’s mandate, and put it in the position it is today?
Definitely, we have to take a historical perspective. So this has been unfolding over decades. The turning point was probably the late 1970s, when there was a historical movement for low- and middle-income countries, the New International Economic Order movement. And they tried to challenge the world economy and how the United Nations system worked. There were a lot of accusations at that time that the UN system was becoming politicized, and organizations like WHO were starting to recognize that it needed to address the developing world’s needs more effectively with the health for all movement and then the essential drugs list. And then there were the breast milk substitutes guidelines that were adopted.
Those all upset certain interests, largely the US and big companies, which didn’t like WHO to stray beyond disease-control programs: things like smallpox eradication, which was uncontroversial. But the US thought that this was straying into territories where WHO shouldn’t be, asking for regulation of the industry, whether it’s food or pharma or so on.
So the US and some other countries — which were shifting to the right at that point under leaders like US President Ronald Reagan and British Prime Minister Margaret Thatcher — they started to freeze WHO’s budget on the assessed contribution side. And so you see the voluntary contributions growing from that point. This is where WHO didn’t have a choice, it had to take more voluntary contributions.
By the 1990s, which is when I come onto the scene and start to analyze this with my colleagues, we did this big study in the mid-90s about financing the WHO and it was about 50-50 at that time, between assessed and voluntary contributions. And that, in itself, was alarming. We said that had to stop. We had to make sure the WHO could set the priorities, not all of these countries and donors, and that’s actually gotten worse.
I think it’s now up to 80 to 85 percent voluntary, and it just continued. So you could see this upward trend. Also, other organizations were created at the time; the Global Fund. Gates came onto the scene, and so there’s been donors putting their money elsewhere, away from WHO.
And WHO said, “We need to be the coordinating body. There’s too many other players out there.” It became a very fragmented, uncoordinated space for action. So we have this crazy, market-driven global health environment, where donors put their money where they want, and create other competing initiatives.
It’s [been] a long time happening, and so what we’re seeing now is, we want the WHO to coordinate, but we haven’t made it the coordinating body for decades. So, it’s very difficult to then step in and get everybody to work together.
It sounds like this distrust has been building for some time with the WHO, which would make it harder for the WHO to inspire cooperation and marshal resources to fight a pandemic. How much does this distrust play into why the WHO is floundering a bit — or at least is perceived to be by some?
WHO has its faults, but I hesitate to say, WHO hasn’t done this, it hasn’t done that. It’s really been like a ship in the stormy seas — with all the changes politically going on, it’s been just buffeted about.
It’s tried to cling onto the fact that it is a scientific organization. They’ve got to wise up. Clinging to this myth that somehow health is not political, it’s actually a losing game.
And if we got rid of WHO now, what do we have instead?
We’d have to rebuild WHO or some global health organization. And the question now is, what would that look like? How would that not be designed by committee, or who would be in charge? Who would have the authority? What would you want it to do?
Then, the politics start again. I’m finding it really a little bit worrying that we come out of this outbreak and we destroy WHO, and we have nothing for the next time. There’s going to be a next time. This is just a warmup.
I’m very concerned that we don’t destroy what little we already have. Instead, go the other way, let’s see what we can do to build up WHO and make it the organization we need it to be.
It might be tough to rebuild the WHO in the middle of the pandemic. But how can WHO be fixed?
This is something I’ve been teaching all term actually, so it’s great that you asked that. I give my students this slide, which has four pictures on it. The first one is an old computer that basically doesn’t work anymore, and you just need to replace it. That’s retiring WHO: in this case, it can’t be fixed, you’ve got to throw it away. That’s, I guess, what President Trump wants to do.
The second one is to keep putting in new peripherals, so you’re plugging in the old extra hard drives. WHO gets all these new programs plugged into an old laptop, and eventually, it can’t run all these things. It’s overwhelmed. That, to me, doesn’t work because you have just too much demand on an old infrastructure.
The third option is to look at what we have, which is a lot of different players out there, and create some sort of network. Somebody has to be in the middle to coordinate, and we have to then strengthen that middle. But to see what other organizations do best, what’s their functions, what are their spheres of expertise — and there are big gaps — so we’d have to create new organizations that do that, but a network model.
And then the other is, if you could imagine an iPad, for example, it’s an innovative idea. Integrate it all into a new product. This picture of the iPad really helped because it’s about creating a new organization where it’s not networked, everything is under one roof, but you think of something very, very different from what the postwar period had.
The postwar period was very much about states, and we still are going to live in a system of individual states that’s not going away. But states alone are not the only important source of authority. So creating something that shares authority in the world and recognizes that the world is changing.
It’s very interconnected. It’s a kind of Star Trek model: we all think of this wonderful world where the world comes together and you have this different governance system. I suspect we’re somewhere in between. We’re still trying to figure out which is the best model to reform global health governance.
What might be a model for a new WHO?
I would say that one of the things that WHO could benefit from — and people are thinking about this — is think about what the world values. We created institutions, gave them power, according to what we value. Over the last 20 years, you’ve seen, we’ve created the World Trade Organization because countries recognize that trade benefits, at least the powerful countries. And probably most countries now want trade to happen in an organized, legal framework.
So WTO was created, and then we have various treaties that countries abide by. If they don’t abide by them, there are sanctions. There are countermeasures that WTO has the power to enforce. If you treat somebody unfairly, your country can go to WTO, make a complaint, if they win, you have either these extra tariffs, or you might not be able to export your goods. There are these countermeasures.
Now, we’re coming out of a pandemic. I think we all value health. We’re recognizing, “Yeah, we’ve ignored this, but health is really important because the world can’t function like this.” This is just insane, is what we’ve realized. We will all shut down if we don’t have a good global health security system.
So what powers do we need to give to this new organization — or reformed organization — to ensure that every country doesn’t go through this again? That means giving up some power at the state level, like the WTO, which has some supranational authority. What do we need to give WHO or something like it to enforce its requirements, and we all benefit from it?
This is what the debate is. What are we willing to give up to get security back? Some are more willing than others. Some countries don’t want to give up anything. Others are like, “Yes, we would want to buy into this.”
But nobody’s escaping from this. We all suffer because we are all interconnected as a global economy. I think even the private companies would get on board with this. They see they can’t operate in a world where there’s no global health security.
But this sounds like it can only exist in a perfect world — and maybe, in a post-pandemic society, things will be different, and people will reevaluate priorities. But I think even the example of the WTO shows the problems with this type of model: we had a global trade war, and the US has bucked its authority, refusing to appoint judges, which renders it ineffective. Basically, it just sounds very idealistic.
And that’s why I say, it’s called a Star Trek kind of scenario. We’re just not there yet. I think it’s going to be an incremental path, and we’re not going to jump to something where we have a universal government.
What we do need to do is think about what do we value in this world? What keeps us all working and moving around the world? What’s the infrastructure we need, and all of us have an interest in buying into?
The global health security system has been underfunded, ignored, despite repeated warnings that we need this. Just like we haven’t invested enough in public health systems nationally, we haven’t done that globally.
And I think it’s going to be a combination of carrots and sticks, to be honest. It’s not just going to be a WHO with enforcement powers to punish. I think we have to create incentives, as well. Whether it’s financial assistance, technical support, public shaming, I don’t know. Just a real range of things.
But certainly, there’s no use accusing WHO of not doing enough. There’s no teeth. The organization has no teeth. It’s just pointless.
It’s a balance that seems hard to strike.
This is what we’re all thinking about. What is it going to look like? How would you do that? You’d need legal expertise, and what international law would offer. You need diplomatic expertise, what could we negotiate?
Russia is not going to just exactly jump on board, or China, or the US, either. These three countries, who are protecting their sovereignty fiercely, are not going to want the rest of the world to tell them what to do.
But there are other countries who are more willing and might go ahead of these three countries. It’s not going to be all or nothing. I think we’re going to have to get like-minded countries together. I think Canada will be one of them, to move and to have a multilateral approach.
It feels a bit as if the coronavirus pandemic has put the world at a crossroads. Countries could turn even more inward, or, more hopefully, they might start looking outward and revive global cooperation. It sort of seems like there’s two ways to go right now.
That’s how I read it as well. There’s a real tension, and I don’t know which way it’s going to go. I’m concerned, and I give these interviews because I want people to go the international route. I really feel that that is the way forward.
But you’re right. Some countries may decide that, no, we’re going to retreat into our castles. It’s kind of a medieval analogy. And obviously that didn’t work when the black plague came along.
Essentially, we’ll learn all the wrong lessons from this pandemic.
You can’t hide from these kinds of outbreaks. This is the thing. People thinking that they can somehow quarantine themselves from these risks is really a dream. So, countries might say, “Okay, we’re going to retreat from globalization. We’re just going to disconnect and become national economies.” And that, of course, is not going to happen.
The global economy has moved so much. We are interconnected. We can’t dial it back. But we have to recognize that we need to invest, as much as we’ve invested in markets, we need investing in strong government and strong multilateral capacity.
So, we are definitely at a crossroads. We’re also at a point in history, I think, where the world has never been as interconnected as it is now. And so the institutions that we built after the Second World War are really out of date.
I talked to my students about being obsolete, like the Maginot line during the Second World War, when the French thought they could stop Germany from invading and built these fortifications.
Now we’re having that same Maginot line moment. We need to think more forward-looking. Does humanity have this in our brains to design something very different? We certainly did after the Second World War. There was nothing like the United Nations. There was the League of Nations, which didn’t really work. So they designed the UN system. It wasn’t perfect, but it got us through a period of crisis. It generally was a good thing that it was created.
Now, we’re at that historic moment. Do we need another global conference? I think we need leadership. Whatever countries are doing well, it’s because they have good leadership. This is such a test.
You mentioned the WTO, but are there any other models or proposals — even on a smaller scale — that could be a good model for this new, iPad version of the WHO?
I wish I did. And if I did, I’d probably be very famous. I think there are parts of different organizations that might be kind of ideas. Like the International Labor Organization brings in non-state actors and state actors within its decision-making body.
I think we do need to think beyond states. I don’t mean by bringing in just big companies. I mean civil society. We have to see, okay, “how do we politically organize our world and who has authority?”
There have been ideas put forward over the last few years about how to adapt WHO. But what I think what will happen is that some countries will get together and plug the financial hole for WHO, and it’ll just continue to lumber on.
But we need to think, after the pandemic, about, hopefully, a different model.