“As dangerous as it sounds.” These are the words that Bill Gates used to describe the blustering, thoughtless announcement by President Donald Trump to suspend US contributions to the World Health Organization (WHO). In this commentary, I look at two key issues that are swirling in the unfolding debate about what the WHO did and did not do – on travel restrictions, for one, but on a freedom of information flow more generally, for another. Although the WHO is being criticized for its actions on these two issues, I believe that they call for more engagement with the WHO, not less. Thank you, Bill Gates!
Personal Experiences in Geneva
To explain my interest in these issues, I knew the WHO well for the three decades or more that I worked in the international world of Geneva. I knew its governance structures, its strengths in public health but also its weaknesses, especially with regard to multi-stakeholder engagement.
First, in the 1990s. I was a senior official in a neighboring international organization (the International Labor Organization) just across the street in Geneva from the WHO. As Deputy Director-General at the ILO, my responsibilities included coordination and engagement with the WHO and other UN agencies. In those years, as globalization opened the world to a burst of multiple non-state actors, I saw first-hand how the ILO brought a constitutional framework of tripartite governance (incorporating worker and employer voices with governments) to the international arena that was missing in these other UN settings.
The multi-sectoral and multi-stakeholder nature of global issues in the 1990s was strikingly reflected in the spread of the HIV/AIDS epidemic. How can one possibly miss the phenomenal emergence of civil society actors to mobilize action against HIV/AIDS at the community, national and global levels? At the ILO, this included tripartite action on HIV/AIDS in the workplace, a very central part of the epidemic since AIDS was an epidemic targeting mostly working age populations.
Subsequently, upon the completion of my term at the ILO, I led an NGO and also worked with individual clients whose priorities were centered on the principle of multi-stakeholder engagement. These included, as an early example, the adaptation of multi-stakeholder action to combat HIV/AIDS, in the world of work. This work expanded to encompass workplace-based action to address other health issues like diabetes and non-communicable diseases more broadly. Our efforts also evolved to address other cross-sectoral issues like access to food and nutrition, with a growing understanding of the social determinants of health, especially in resource-limited settings. All of which brought me and the NGOs I worked with to monitor ever more closely the governance of the WHO – and to appreciate both its strengths and its weaknesses. Both are clearly on display in the Covid-19 crisis.
Strengths amd Weaknesses of the World Health Organization
The strengths of the WHO are considerable, to be sure. It is the sole international body with the established mission to promote “the attainment by all peoples of the highest possible level of health”. It stands out for enabling the world to eradicate diseases like smallpox and to do the same for other contagious diseases like measles or polio. It does much more, of course, on primary health care, on maternal, newborn and child health, on cancer and other chronic diseases, on access to medicines and health products, on the health workforce and health systems generally. I have been duly impressed with the range of global health policy issues that are tackled at the WHO.
I would also like to explain my views about the WHO’s weaknesses. They have to do with the WHO’s approach to managing multi-stakeholderism in the public health arena. As mentioned above, the WHO was slow on the uptake on HIV/AIDS – and long since corrected, of course. But it was the resistance worldwide (and at the WHO) to see HIV/AIDS as a human rights issue that mobilized the emergence of numerous activist organizations to address HIV/AIDS. It was a precursor of a continuing agony at the WHO on how to manage its relationship to non-state actors, whether these are advocacy NGOs, development NGOs, philanthropic foundations, businesses or hybrid organizations mixing the various kinds of health-related interests. This requires more elaboration, to be sure, but suffice it here to say that the public health (governmental) networks that represent the member states in the WHO are still working out how to relate with these non-state actors – or, to use a different word, these multiple “stakeholders”.
WHO and Emergency Preparedness
In spite of the WHO’s reputable record on eradicating smallpox or controlling polio or measles, emergency preparedness for the prevention or control of new sources of contagion has not yet become one of the strengths of the WHO. One can dwell, as noted above, on the slow pick-up on HIV/AIDS at the WHO, but I also believe that the lessons learned from the HIV/AIDS experience did actually contribute to efforts at reform. One of these, still in flux, was the effort to rewrite and expand on its policies for dealing with non-state actors. More importantly, it clearly inspired the decision by the 1995 World Health Assembly to rewrite WHO policies more broadly on emergency preparedness for global health emergencies. This consisted of a major revision to a document known as the International Health Regulations, based on a 1951 version that was clearly outdated. But it apparently involved a lot of foot-dragging, and finally took ten years – and another health crisis – to get this done!
One could argue that the WHO leadership did rather well in helping China to control the SARS epidemic in 2003-2004. We still remember the loss of Pekka Aro, an ILO official, in that outbreak, and yes, the outbreak was effectively contained. But it was this new and alarming virus that contributed to the final momentum for the updating of the International Health Regulations in 2005. The IHR (2005) established an improved framework for managing the growing multiplicity of potential outbreaks (including HIV/AIDS and SARS) and their greater threats to becoming global, due to the expansion of trade and travel and international exchanges of people. It went into effect two years later in 2007, with 196 ratifying parties.
The International Health Regulations (2005) have been widely praised as a legally binding instrument of international law for controlling the international spread of diseases and other health risks,. It calls upon all member states to establish public health surveillance and response capacities. Most importantly from my perspective in this commentary, the IHR (2005) was an effort to extend WHO authority to reach beyond border controls to include containment at the source of an outbreak. The idea was to have each and every participating country establish core capacities to handle a public health hazard (such as SARS) and to accept the obligation to officially and quickly report any such hazard to the WHO, regardless of whether it was approaching or crossing a border. However, compliance with IHR (2005), even though “legally binding”, is up to each country, and enforcement is essentially voluntary. Emergency preparedness thus depends first and foremost on preparedness at the country level, and especially in the country where the emergency event arises.
Travel and Trade Restrictions
The dependence on the governments of member states for compliance with emergency preparedness does get complicated, especially when it relates to other global interests. Integral to the IHR (2005) was the idea that controlling the spread of disease and other health risks was important in its own right but was especially of global concern because of the increasing danger of the cross-border spread of disease or other health risks to international flows of traffic and trade (and, by the way, international exchanges of people). I do believe that this was a credible priority in the WHO’s International Health Regulations (2005) – and that it is still a relevant priority today. There was, after all, quite a history of unjustified trade and travel restrictions, imposed by governments out of an irrational belief that they could isolate something like a cholera epidemic. And here we were with lots more globalization and lots more, new virus risks than in years past.
It is disturbing that President Trump boasts about his abruptly closing of travel of “non-US citizens” from China to the US on 31 January as the right thing to do, in spite of the IHR recommendation to the contrary. It is disturbing because President Trump’s action was the very kind of discriminatory and arbitrary ban that the IHR (2005) sought to discourage. Of course, the spiraling nature of the pandemic did lead to more and more borders being closed. And no one wants to dispute the importance of the “stay-in-place” nature of the lock-downs. BUT he has chosen to take credit for imposing a partial and discriminatory travel restriction in January as though it was the right thing to do at the time.
One can argue that this Covid-19 virus caught everyone by surprise – that no one fully understood how deadly and contagious it could be. Well, we are now in a situation where no one is going to travel willingly on an airplane to anywhere for fear of Covid-19 contamination. So one has to conclude that the draconian travel restrictions we are living with are justified – under the circumstances. They can’t control the spread of a disease that has already spread.
But this puts us into an entirely different world than ever before. We have a global pandemic that has no vaccine or other reliable defenses to protect us against infection, no therapeutics to treat the infection, no mechanisms to monitor non-symptomatic carriers, and no reasonable systems yet found to track and isolate those who are infected. These are all in the works, of course. If we get to that point, the big question will be whether any of the trade and travel patterns that we had become so used to will return to their widespread use. Or whether we will have new patterns.
In concluding this point, the discriminatory nature of what President Trump did in January seems to be in the process of being repeated by his most recent Tweet to block all immigration into the United States. I believe that there is enough evidence here to suggest that selectively closing the air traffic from China could have been avoided if the Chinese and/or the WHO could have acted more quickly. Even more serious now is the preposterous notion that a country can close down all legal immigration on the grounds of a global health emergency. This reinforces the IHR (2005) emphasis on avoiding “unnecessary” trade and travel restrictions. In a post-pandemic environment, it will be important to explore how this can be better managed. But I would also argue that doing anything about this at the WHO would require overriding the IHR (2005) provisions that rely on national reporting and action. This leads me to a second and more important point about this pandemic in the context of the International Health Regulations.
Freedom of Information Flow – or “Complementary Mechanisms”
To return to the discussion earlier in this commentary about HIV/AIDS, one cannot effectively depend on national or governmental action alone to combat – or even to recognize the existence of – an epidemic. It requires openness for community engagement but also for information to flow freely. We know that certain early warnings of a new kind of pneumonia in Wuhan were repressed by Chinese authorities and that certain courageous individuals were punished. We also know that critics of the WHO are citing these warnings as the basis for condemning the WHO’s own cautious approach – deferring WHO action, as they apparently did, to receipt of the official Chinese reports on the nature and scope of the virus instead of acting on the earlier unofficial news reports.
Without going into more of the technical details but in defense of the WHO from a layperson’s perspective, it seems that the WHO did get mobilized very quickly. With reports filtering out on 31 December, the WHO immediately pulled together an “Incident Management Support Team” on New Year’s Day, 1 January 2020. This was a holiday. And yet, there they were already working on the bits of information that were filtering in, while the rest of us were mulling over our New Year’s resolutions!
Regrettably, the official communication flow from Chinese authorities was erratic and only confirmed the seriousness of the virus some weeks later. Should the WHO have gone ahead to dispute the erratic information flow? Well, the IHR, even in its 2005 iteration, continues to protect governments from being overridden by non-official sources of information about a public health emergency. It is good that the drafters of the revised IHR recognized that outbreaks need to be reported to the WHO as soon as they appear and not just when they are threatening to cross a national border. But the authority to report on any such outbreak remains in the hands of the member government.
The extent to which a governing body made up of national governments can do anything differently than protect its own sovereignty is debatable. Yes, something like that did happen in the formation of UN AIDS. As it did with the ILO many years ago. Governance CAN include non-state actors. As for how to apply that to a country like China, where there are no truly independent non-state actors…, well, yes, this is even problematic when it comes to these bodies. At the ILO, for example, there have been very heated debates about the independence of employer and worker representatives from governments, and there is even a mechanism to challenge delegations to the International Labor Conference. At the WHO, on the other hand, there has been absolutely no flexibility for non-state actors to become part of the governance processes. The closest it gets is a Framework for Engagement with Non-State Actors, which at least recognizes that they exist but sets up barriers for almost all of them, most particularly any with a private sector identity or association, to participate in any aspect of the WHO’s governance.
To return to the way this is handled in the IHR (2005), the latest review of the emergency preparedness process by the WHO Executive Board was last February, just a few months ago. It, too, was disappointing on this issue. The Board had a report from a Global Preparedness Monitoring Body that the world was dangerously unprepared and concluded that urgent action was needed. The Board then adopted a resolution on “Strengthening preparedness for health emergencies: implementation of the International Health Regulations (2005)” that goes into considerable detail about improving capacity and existing oversight mechanisms.
In the resolution, member states, it should be noted, are urged to “prioritize community involvement and capacity building in all preparedness efforts, building trust and engaging multiple stakeholders from different sectors…” We are seeing a lot of this as NGOs, businesses, entertainers, and individuals are mobilizing efforts to help people – and to help the WHO. However, this is not the same as calling for stakeholders to participate in the actual reporting of an outbreak. On the matter of opening up the information flow to other stakeholders, the resolution is disappointing. All it does is to request the Director-General (italics added):
to conduct a study in consultation with Member States on the need for and potential benefits of and, as appropriate, make proposals… on possible complementary mechanisms to be used by the Director-General to alert the global community about the severity and/or magnitude of a public health emergency in order to mobilize necessary support and to facilitate international coordination.
The closest we can get to independent information flows is for the DG to “conduct a study”? What is more, the study has to be safely conducted and thus only “in consultation” with the Member States? And, furthermore, this study is only authorized to propose “possible complementary mechanisms” for the Board to then consider, “as appropriate”? This is pathetic, but it is the way of the UN. Critics of the WHO might complain that the DG and staff have been too deferential to the Chinese state, but the IHR (2005) has no alternative for the WHO but to rely on official reporting.
Just as the matter of knowing what it means to unnecessarily restrict international trade and travel is undergoing change, so we are confronted with a growing demand to change the way that information flows are recognized. One can hope that the review of what happened to make this pandemic so awful will open up new ways for us to manage “unnecessary restrictions” to the cross-border travel and trade (without closing the world down) and new ways to introduce whatever “complementary mechanisms” we need to support and facilitate international coordination.
We need a world in which international travel and trade can operate with limited restrictions for public health, and not across-the-board closing of all flights and cruises or international exchanges of people. We need a world in which there is a free flow of information, communication and collaboration. We need individuals and groups expressing themselves in multiple stakeholder ways. These can and should be channeled through representational mechanisms, but it is time for us to open up, including at the WHO. The strengths are there for the WHO to be the global forum we all need, and the weaknesses are there for us to address by actively engaging with the WHO, not closing it down.