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The importance of simultaneously strengthening and constructively criticizing the WHO

In the midst of the largest global health crisis in decades, the United States of America initially ceased all payments to the Geneva-based World Health Organization (WHO) in the middle of April 2020, and then proceeded to announce the country’s withdrawal from the organization. During a press conference in the rose garden of the White House on 29 May 2020, US president Donald Trump justified this with China’s alleged total control over the WHO, and with the WHO’s refusal to implement urgently needed reforms.

Eva Wuchold leads the Rosa-Luxemburg-Stiftung’s Global Social Rights programme at the RLS office in Geneva. This article originally appeared in maldekstra #8. Translation by Lisa Vogel.

As early as April, the General Secretary of the United Nations, António Guterres, sharply criticized the decision of the US, who in 2019 contributed more than 400 Million US dollars or approximately 15 percent of the overall budget to the WHO and thus had been the organization’s largest source of funding. Now, in the midst of the crisis, was “not the time” to reduce the committee’s resources. Guterres went on to say that the WHO was “absolutely critical” to the eradication of COVID-19.

Nonetheless, Trump is not alone in his criticism of the WHO and the Chinese influence on it.

Research conducted by the Canadian Citizen Lab shows that the Chinese government had attempted to prevent media reports about the coronavirus. Even towards the WHO, the Chinese government did not act transparently, contrary to what the organization itself initially claimed. The time of the criticism and the USA’s withdrawal from the WHO, however, bore witness firstly to a misjudgement of the current crisis, and secondly to a lack of knowledge of the organization’s mandate to act and its mode of operation. The WHO is an intergovernmental organization, which can only act according to what its member states and other funders allow. The political disputes that take place within it lead to the fact “that the WHO with its 194 member states cannot govern as purposefully, quickly, and outside of procedural rules, as we can currently observe to an unprecedented extent even in countries with democratic constitutions”, according to Anna Holzscheiter, head of the research group “Governance for Global Health” of the Berlin Social Science centre.

As important as it generally is to criticize the in many cases dysfunctional structures of the UN and its sub-organizations, it is important especially in a big crisis to stand behind the organizations that are attempting to overcome said crisis, as was expressed in an appeal of the Civil Society from 15 April 2020. The appeal posits that it’s high time “for all member states of the WHO to recognize and support the enormous value of the organization in the comprehensive handling of the health challenges that are ahead of us due to climate change and other threats, instead of using their own errors as an excuse to further weaken the leading role of the organization in the protection of public health”.

The UN and the WHO occupy a central role in the global management of the health crisis. The WHO, founded in 1984, can fall back on decades of experience dealing with pandemics. With its 194 member states, it is able to coordinate international and national activities such as emergency aids in the fight against pandemics, control collaboration on the development of tests, medications, and vaccines, or pronounce concrete transnational recommendations for action such as quarantine measures or travel restrictions. Additionally, the WHO has an advocate in the UN General Secretary, who can make its concerns heard globally and furthermore pronounce recommendations for overcoming the health crisis, as evident in Guterres’s appeals for a worldwide ceasefire on 23 March 2020.

On that basis, reforms of the WHO should be considered and tackled. As early as 2015, Thomas Gebauer, director of medico international at the time, lamented that there were management problems within the WHO and that its structure needed to be improved upon. A reason for this were cuts in the WHO’s budget for the control of epidemics, since health was no longer only seen as a human right, but was subordinated to economic interests. The WHO’s programme budget 2020/21 amounts to a mere 4.8 billion US dollars. The mandatory contributions of the member states, which are especially crucial for the WHO’s work, now only make up a fifth of it. The mandatory contributions have already been frozen since 1993, and the WHO increasingly receives purpose-specific voluntary payments. Since the former UN general secretary Kofi Annan opened the UN to private financial sources in 1997, the share of politically sensitive contributions of private foundations and businesses has been on the rise. In 2012/13, the Bill & Melinda Gates Foundation was the largest sponsor of the WHO, even ahead of the USA, which accordingly led to consequences for the WHO’s programme: Away from the strengthening of public health systems, towards combating a few individual diseases such as tuberculosis or malaria, where quick and inexpensive successes can be produced with vaccines and mosquito nets.

But the current crisis can only be contained with a massive strengthening of the global public health sector, especially in the global south, where the course of the pandemic cannot even be anticipated yet. Since the countries of the global south do not even come close to having the financial means for this, the international community will also be in demand here. This only begins with the call of the World Bank and the International Monetary Fund in March 2020 to suspend debt repayments from the poorest countries for the time being, as well as the agreement made by the G20 members in the middle of April, which decided on the deferral of all interest and loan payments for the 77 poorest countries from May to December 2020. In order to prevent other epidemics and to further be able to tackle health crises like the current one in the future, the middle- and long-term goal will be to restore the independence of the WHO, for which a massive increase of the low mandatory payments is central.

But this requires the majority of member states to change their thinking. Stagnation and reduction of the mandatory payments to the WHO further contributed to its decline, since more and more health-related measures were relocated to other institutions, initially to other UN organizations, but later also to public-private partnerships like the Global Fund or the Global Alliance for Vaccines (Gavi), and finally to multi-stakeholder initiatives. Such arrangements, supported by the World Economic Forum and even the UN, had the effect that “the WHO is merely one partner amongst many and no longer—as would correspond to its mandate—the coordinating authority for fostering global health and for the protection of health as a ‘fundamental right’” according to the Canadian scientist Anne-Emanuelle Birn.

In order to once again do justice to its founding principle to achieve the highest possible level of health for all peoples, the WHO must return to the organizational goals outlined in its constitution: namely, to contribute to an improvement of the overall living conditions on the basis of substantiated and independent scientific findings. Additionally, the effectiveness and success of strategies once again needs to be measured according to whether they contribute to more health justice, not whether they conform to the market. Only then can the WHO do justice to its role as the central and the only democratically legitimized entity in global health questions and take a leading role in the global health field in the future.

As the WHO already recorded in its world health report in 2008 and as medico international demanded anew in 2018 for the 40th anniversary of the declaration of Alma-Ata (Kazakhstan), the closing document of the WHO conference of 1978, the principles of so-called “Primary Health Care” are central to this. In order to put this into practice, health must be recognized as a “fundamental human right” and the system as such must be democratized: on the level of employees, such as through the support of movements for more staff in hospitals, and on the systemic level, for example through the democratization of the formally still existing self-governance in the health sector, through the inclusion of patients or insured persons in decisions in the health sector, or through a health insurance model that is based on the principles of solidarity and non-monetary benefits.

The pressure for change must come from below, from well-connected and persistent forces of civil society. Already—still in the midst of the pandemic—there are discussions on which lessons are to be drawn from the pandemic, whether in relation to essential institutions, businesses or professions, but also in relation to ways of production and labour, for example in the meat industry. Simultaneously, the corona pandemic must be embedded into a larger context. Like all pandemics, it is also a reflection of global inequality. This is shown for one by its spread in countries like Brazil, Mexico, or India, where millions of people were exposed to it without protection, but also by the emergence of so-called hot spots in Germany in places with particularly cramped living conditions or precarious employment. Furthermore, there needs to be a debate about the effectiveness of multilateralism, its organizations and instruments, as well as on how this concerns the current health crises, the climate crisis, or the subject of war and peace.