Confronting COVID-19 In A World Without WHO – Seriously? Inside View 14/04/2020 • Frederick M. Abbott Share this:Click to share on Twitter (Opens in new window)Click to share on LinkedIn (Opens in new window)Click to share on Facebook (Opens in new window)Click to email this to a friend (Opens in new window)Click to print (Opens in new window) The White House in Washington, DC As the World Health Organization becomes the target of attack by President Trump, his administration and political allies for its alleged failures in response to the COVID-19 pandemic, the main points of critique are reverberating throughout the media in an escalating cycle. After a week of mounting criticism, Trump announced on Tuesday night that he had instructed the administration to suspend funding while an investigation was conducted into WHO’s handling of the crisis. His statement came a little more than 100 days after China first reported the mysterious outbreak of the pneumonia-like virus – even as the agency attempts to contain the pandemic’s spread to vulnerable low-income countries of Africa and South-East Asia. “The WHO failed in its duty and must be held accountable,” Trump said in the daily White House Taskforce briefing. While Legitimate evaluation and critique are important, a question that must be asked, however, is whether any shortcomings and mistakes made were uniquely WHO’s? Or is the global health agency also being targeted as the “fall guy” for errors made by its member states, including the United States – which is presently the epicentre of the pandemic. A more critical question is: would the world be better off without the WHO? Or is it an agency that we urgently need to coordinate the global response to outbreaks; to synthesize available evidence on effective responses – whether these are at national or hospital level; and to support those countries and health systems that lack sufficient resources to respond on their own? Main Points of Criticism: Technical Errors & Pressure Politics Donald Trump speaks at the daily White House Coronavirus Taskforce briefing Boiled down to the essence, the main points of critique by President Trump, other US administration figures and political allies are running along two lines: WHO leadership bowed to Chinese political pressure in making decisions – refraining from recommendations for more forceful measures such as travel restrictions. And it praised Chinese responsiveness while it avoided criticizing its initial concealment of the outbreak in Wuhan – what Trump described as “China-centric” policies. WHO failed to properly assess and communicate the risks from the COVID-19 virus, particularly in the early days, with respect to a range of medico-technical issues, such as early determinations of whether the virus was being transmitted person-to-person. Trump criticized WHO’s early opposition to travel restrictions, calling it “one of the most disastrous decisions.” Although criticism of the technical decisions, as well, is enmeshed in politics – with Taiwan’s government asserting that it warned WHO early on about the person-to-person risks, only to be ignored. Had these failures not occurred, the argument goes, the international community — and particularly the United States — would have been spared the scale of human suffering it has experienced. The criticism repeated by President Trump in White House press briefings, and echoed by key political allies, has been coupled with threats to suspend funding to WHO, which amounted to US$400 million in 2019. Congressional Republicans now appear poised to shortly follow up on those threats – even if cooler voices have pointed out that cutting funding during the pandemic might not be the best idea. Crises and Pressure It is not surprising that WHO is subject to political attack as deaths from the spread of the pandemic accelerate. National (and more local) political leaders are under great pressure. Their constituents are dying. The role of government is to protect the health and safety of its citizens. People will hold their governments accountable. If misguided actions, or omissions to act, have demonstrably contributed to the scale of suffering, the adverse political consequences loom large. Almost inevitably, a national government that failed to heed warnings will seek to shift blame. The WHO is a made-to-order target. Its name is enough to suggest that the organization might be held responsible for the consequences of the pandemic. WHO officers and staff are not a voting constituency. Regardless of what China did or did not do, there is a motive anchored in political expediency to blame the Chinese political leadership as this fits squarely with the Trump Administration’s agenda of portraying China as a bad actor and strategic threat to the United States (while episodically praising it). The aim here is not to determine definitively what the WHO or China did or did not do. Rather, it is to point out that for his domestic political constituency these are the logical places for President Trump to re-direct responsibility in the COVID-19 crisis. Regardless of facts, there is nothing surprising about this from a political standpoint. WHO Leadership Dr Tedros speaking at WHO’s regular COVID-19 press briefing. A substantial part of the US criticism of the WHO is directed toward its leadership and the “real-time” decisions that the leaders, especially Director General Tedros Adhanom Ghebreyesus, have made. The WHO Director General has a margin of discretion in terms of his decision-making. But he relies on input from many technical experts within and outside the organization. In the case of a pandemic, and under the International Health Regulation, the Director General acts with the advice of an Emergency Committee. The Director General will have received technical input from scientists, logistics experts and so forth from around the world, including the United States, China and Europe. A WHO Director General will be responsible for weighing and balancing the technical opinions he or she receives, but those decisions are based on a body of evidence and opinion. At the same time, any WHO Director General understands that he (or she) will also be judged personally for decisions that were made. WHO’s Global Role – Its Mandate is Limited by Member States The WHO, governed by its member states in the World Health Assembly and Executive Board, is the forum where governments and other interested stakeholders discuss and agree upon policy and implementing measures to advance the promotion and protection of public health. The WHO provides the network framework for cooperation to address common challenges. In the counterfactual where there is no WHO – or it is “hypothetically defunded” — what is going to be the alternative? What will be different? The WHO is deliberately designed with very limited autonomous authority. If a national government — China for the sake of argument — refuses or delays allowing WHO scientists to enter the country, the WHO cannot and does not send paratrooper virologists to stage a raid. The WHO has powers of persuasion, but those are of debatable strength. In terms of budget allocation, WHO members have also deliberately pursued a system of earmarked funding in recent years that assures national control over the WHO work program. This has made it difficult for WHO to establish its priorities based on global and regional assessments of public health needs, an issue that Dr Tedros has sought to address. The Gates Foundation is another major source of funding for WHO activities, and due to that, it also plays a substantial role in directing the work of the organization. Is the new and improved WHO-alternative going to be given “sovereign authority” to act – even against the wishes of member states? Will it have its “own” budget controlled by that sovereign authority? Or, would any new WHO-alternative be even weaker from a political standpoint than “old WHO”? The critical point is that we need an institution like the WHO because public health concerns such as pandemics are global. What happens in Burundi may very well affect people in Toronto. Leaving aside the ethical questions, high-income countries cannot permanently wall themselves off from the impact of pandemics by sealing their borders, refusing to trade and preventing their citizens from traveling. Or if they theoretically might do that, we would be living in a very different – and poorer – world than the one we are living in today. Only the most radical isolationists might be seeking such a result. Technical Decisions – Ensuring Feedback Loops & Avoiding Politicization Against this landscape, much has been made of the decisions made by WHO on medico-technical issues such as its initial uncertainty over whether there had been person-to-person transmission of COVID-19; whether and when to recommend travel bans; whether and when to declare the outbreak a pandemic; and whether to recommend wearing face masks. These decisions have been made, and continue to be made, in situations of substantial uncertainty. In hindsight WHO might have more quickly extrapolated the first few reports of facile person-to-person transmission into grounds for a major change in risk assessment. But the grounds were shifting here in light of initial reports coming out of China that human transmissibility was more limited. With respect to travel bans, at the time that WHO resisted calling for such measures, a preponderance of public-health specialists were also opining that travel bans were likely to be ineffective because borders are porous; they can restrict critical economic trade; and the imposition of bans may provoke precisely the type of infection-carrier exodus they are trying to prevent. Keep in mind, as well, that this outbreak has posed challenges unlike others seen in the past century, including SARS, Ebola and H1N1. That said, there is strong evidence that travel bans, when they are used, need to be planned and prepared so that they don’t lead to unintended consequences that facilitate further virus transmission. This was evident immediately after the United States announced a travel ban on passenger arrivals from Europe. This triggered a wave of departures from European airports, with thousands mobbing European and then US arrival terminals for many hours – creating a fertile ground for the virus to spread. Travelers at Madrid-Baraja Airport, Spain’s largest international airport. The airport is nearly empty after an initial rush of travelers in mid-March, right after the US enacted travel bans for Europe. The WHO and other public health authorities will certainly need to revisit the utility of travel restrictions in the wake of the COVID-19 pandemic based on experiences gained. It is almost inevitable that some decisions made in the course of a pandemic will be in error. Everything is not foreseeable or pre-programmable. The question is not so much whether errors will be made — though obviously this should be kept to a minimum — but how well the feedback loop works so that mistakes are quickly corrected. Many national (and local) governments, including the United Kingdom as well as large parts of the United States, initially elected to go about business-as-usual, avoiding business and school closures and stay-at-home orders. Once it became apparent that lockdowns of some sort were one of the most effective tools to contain the spread of the virus most of those governments corrected the mistake. The egregious failure is by the government entity that has the “better information” and refuses to act on it. When the history of the COVID-19 pandemic is written, it is likely that some of the decisions at least initially made at WHO will be assessed as errors. Errors made in the course of a pandemic are likely to cost lives and they cannot be treated lightly. The main thing is that the appropriate lessons should be drawn so that they are not repeated. The China Question – Did the US Listen to its own Intelligence Services? Residents in Wuhan buy daily necessities and food across closed fence gates during the lockdown in China. Perhaps the most politically fraught set of issues goes to the question “what did China know and when did it know it?” I do not have the answer to that. It is “above my pay grade”. What seems clear based on current reporting is that the US government through various information channels became aware of an outbreak with potentially very severe consequences early on and that President Trump was apprised of this information. The President delayed domestic preparedness, even weeks later assuring the public that the virus was something over which we have “tremendous control”. If the President chose to ignore information coming from US intelligence services and other presumably reliable sources, what difference would it have made if the WHO (or the Chinese government) conveyed information about person-to-person transmissibility a week or two earlier? None of this would excuse the Chinese government if it deliberately withheld information critical to the international community at large, but it does go to the heart of the political dynamic within the United States and harsh criticism aimed at China (and indirectly at the WHO). Shouldn’t the United States President have trusted his own intelligence apparatus without confirmation from the Chinese government? COVID-19 Reaffirms the Need for a Global Health Organization (left) World Health Organization Headquarters in Geneva (Photo: WHO/P. Virot).(right) White House in Washington, DC (Photo: Obama Whitehouse Archives) The WHO was founded because the international community needed a forum where public health issues of collective concern could be assessed and addressed. It was not founded to host political debates and resolve strategic disputes — for which there are alternative fora. The COVID-19 pandemic reaffirms the continuing need for such an organization. The circumstances of this pandemic argue in favor of increasing funding and strengthening cooperation and coordination mechanisms, not for weakening them. There are no “perfect” international organizations, just as there are no perfect national governments. Judgments made in real time based on imperfect information will not always be optimal. In the case of the WHO, judgments are based on processes that filter incoming data through a range of scientific experts. A judgment by the WHO Director General may turn out to be incorrect, and it should be corrected promptly. The Director General and senior WHO leadership understand that what is done during an outbreak will be analyzed and assessed by history. The WHO, however, should not be the place where national governments offload their own errors in judgment made with their own, and perhaps even better, information as well as (at times) resources. Some countries that were just as vulnerable to the virus as the United States responded earlier, and in different ways, and have been spared its worst consequences. While the WHO is supposed to provide evidence-based guidance to national decision-makers, ultimately it is up to national governments to act – and that is what the WHO has urged them to do, more than anything, from the beginning – to get ready, to be prepared. Will the US, or leaders of other WHO member states for that matter, acknowledge the mistakes they have made: the failures to prepare hospitals sooner; failures to acquire protective gear; failures to ramp up testing rapidly? President Trump, like others, made decisions early in the crisis under circumstances of imperfect information – that needs to be acknowledged. The problem for President Trump is that he insists that his instincts are perfect, so that if errors were made they could only have been made by someone (or somewhere) else. Acknowledging error undercuts a claim to perfection. And President Trump is not alone on the world stage today claiming that kind of instinct. Director General Tedros has not claimed to be perfect, or to have made perfect decisions. His appeals have largely centered around another theme – solidarity. He has called on world leaders to put politics aside while countries confront a bigger enemy than each other. That call goes increasingly unheeded. Like COVID-19, the accelerating pathogenic deterioration in international discourse needs to be contained so that the world can confront future pandemic threats with an even more effective WHO. ______________________________________ Frederick M. Abbott is Edward Ball Eminent Scholar Professor of International Law at Florida State University College of Law, USA. He has served as expert consultant and legal representative for numerous international organizations (including the WHO), governments and NGOs, mainly in the fields of public health, intellectual property and technology transfer, trade, and sustainable development. He is Co-Chair of the ILA Committee on Global Health Law. He served as a member of the Expert Advisory Group (EAG) to the UN Secretary General’s High-Level Panel on Access to Medicines. http://frederickabbott.com Image Credits: WHO/Pierre Virot, Library of Congress/Carol Highsmith, White House/D. Myles Cullen, Wikimedia Commons: Nemo, Wikimedia Commons: Painjet. 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