Health and peace, sex and war, money and management. Whether in chorus or cacophony – last week’s World Health Assembly of WHO member states played most of the notes in the symphony of global debate over strategies to tackle disease, epidemics and pandemics and bolster health systems. But the root causes of emerging disease threats – in modern environmental health threats and nature gone awry remained under-represented themes.   

From the opening notes of the WHA, on a health for peace theme, to Saturday’s late night closing and end-run charges over language on sexual orientation – this year’s WHA was a seesaw of successes and setbacks.

Highs included the consensus vote Tuesday to increase member states contributions to WHO, followed by a resolution Friday to move ahead on the first real reforms to the International Health Regulations in almost 20 years.  

And at the same time, unprecedented polarization was evident during Thursday’s debate over a resolution condemning Russia’s invasion of Ukraine, which won approval by a vote of 88 to 12. 

That was followed by the dispute that emerged Friday and continued until nearly midnight  Saturday over references to terms such as “sexual rights” and “men who have sex with men” (MSM) in a WHO strategy on HIV, hepatitis-B and sexually transmitted infections (STIs). That, too, was resolved only by a painful series of rollcall votes, leading to the strategy’s passage by just 60 member states, with twice as many delegates absent or abstaining. 

Like a bullet train ride 

Dr Hiroki Nakatani, who presided over the committee that faced the thorny final hours of WHA dealing with the clash among nations over sexual health terms that HIV professionals regard as the standard usage, compared this year’s WHA session to a ride on a bullet train. 

“The train ride was sometimes bumpy but we arrived at our destination,” he said of the first Assembly to be held in person in several years because of the pandemic.

Perhaps so, even more so than the war in Ukraine, the exceptionally large number of abstentions in the vote on a new HIV, Hepatitis and STI strategy was a bitter pill to swallow for delegates on both sides of the debate. 

It highlighted the fact that the battles still being waged in Europe, the Middle East, Asia and Africa over the control of territory are not the only big issues dividing member states. Fissures over social norms shape and guide public health policies run just as deep.

Sex & War – Global social divide as deep  as territorial conflicts 

And among those norms, there remains a deep divide around health policies that interface with human sexuality – that other primordial urge that co-exists alongside the urge for power and territory. 

For WHA delegates, in fact, the series of votes Saturday over sexual terminology may have been even more unsettling than the votes over Russia’s invasion of Ukraine – precisely because they sit in Ministries of Health, not Defence, with day-to-day responsibility for designing and implementing policies on HIV and other STIs.  

As with the Ukraine conflict, the divide that emerged, however, was not strictly drawn along the lines of global North and South.

Rather, it was the oil-rich Saudi Arabia that led the charge in the quest to purge references to men who have sex with men from the strategy on HIV treatment, followed by emerging economies of Asia and Africa where conservative views about sexual expression are often protected by law as well as custom.   

Against that, was Europe, North America, much of Latin America  and high-income Asia- where more new attitudes about gender identity and LGBTI terminology have taken root over the past few decades. 

There were also exceptions, such as South Africa, which voted in favour of the HIV strategy.  And European Serbia abstained from the vote as did the Russian Federation. 

Respect for culture, versus respect for evidence  

In the aftermath, the abstaining countries pleaded for more understanding of norms guided by tradition and culture. Western delegates, meanwhile, referred to the compass of science – whereby recent research has revealed how oft-marginalized MSM groups often fall through the cracks of programmes for HIV/AIDS prevention, diagnosis and treatment.

“We appreciate those member states acted in good faith as part of these deliberations. Unfortunately this has served as a painful reminder of the need to reinforce our focus on evidence, human dignity and decency,” said US Assistant Secretary of State for Global Health Loyce Pace just after the strategy was approved.  

“[But] we should not need to hold a vote on the existence of entire communities of people,” she added.  “We have a strategy on critically important global health issues, yes. But at what cost to those we risk leaving behind?

“So to gay, lesbian, bisexual, queer, intersex, transgender and gender non-conforming people around the world, the United States government sees you, and will continue to support you.  Stay strong.”

Reviewing the issue at Monday’s Executive Board meeting, member states on both sides of the divide expressed concerns over the failure of the WHA to find consensus over such a flagship health strategy – and the “dangerous precedent” that the voting set. 

“It is important that this does not set a precedent for consideration and adoption of technical documents by the Health Assembly,” said Dr Edwin Dikoloti, Botswana’s Minister of Health and Wellness, speaking on behalf of the African group, saying that greater efforts need to be made to find consensus in future WHAs over such controversial issues.  

Money – landmark decision on WHO finance – but not a ‘done deal’ 

The holy grail of consensus was restored in other key moments – including around the WHA resolution to increase regular member state contributions to WHO – in a bid to stabilize the agency’s finances 

The agreement, the fruit of months of grinding backroom diplomacy led by Germany, saw member states commit to  increase annual assessments to cover  50% of WHO’s core budget by the end of the decade. 

However, each stepwise increase up until 2030 will still need endorsement at future WHAs to go forward.  And so the vote should not be seen as a blank check either, a senior official in the Department of Health and Human Services, told Health Policy Watch. 

“I would say that the US, as a big contributor to the WHO, is definitely committed to that [resolution], and we were very happy to join the consensus,” the official said.  

“But I hope it’s also been clear that that is not a done deal and neither for us as the administration or for Congress.”

According to the resolution, final approval of each year’s increase is contingent on progress in WHO internal reforms that are supposed to make the organization more transparent,  efficient and well-managed. 

Those demands include overhaul of WHO’s budget management system, said the senior US official: “The budgets that are adopted by the Health Assembly are not real budgets. They’re just budget space. And creating budgets that are aspirational is very different from programming and reporting on and demonstrating the impact of real budgets.”

Management – following election Tedros faces new demands  

But the expectations go beyond budget reform, pressing newly re-elected Dr Tedros Adhanom Ghebreyesus for changes in WHO’s management culture, including more merit-based appointments of senior WHO staff, such as those serving as heads of WHO country offices, and structural reforms in WHO’s internal justice system.

“I think, from our perspective….  there’s a very significant culture change… that needs to happen within the organization,” the official told Health Policy Watch.   

Further related to that, are demands for a “full resolution” of the ongoing investigation of the cases of sexual harassment and abuse of women in the Democratic Republic of Congo by WHO staff and consultants, whose progress also was reviewed at last week’s WHA and Monday’s EB.     

Justice – WHO internal justice system lacks independence  

While the revelations of the DRC sex abuse scandal, which first came to light in 2020, and whose perpetrators have yet to be fully prosecuted, highlight failures of WHO internal justice to date, they also are evidence of a broader and more systematic problem, some WHO insiders maintain. 

One key problem, highlighted in multiple interviews with both past and present WHO staff, is the fact that WHO’s Internal Oversight Office (IOS) – the legal mechanism that manages staff and management complaints – is housed in the  Director-General’s Office and effectively controlled by the Director General himself – rather than at arms length. Politically influential managers or staff with the ear of the DG, may receive different treatment than staff who do not, critics say.   

The flaws in the current process featured in a WHO Staff Association letter to Monday’s Executive Board. The Staff Association demanded that the WHO Global Board of Appeals, the three-member body that hears cases, and recommends disciplinary action to the Director General, be expanded and also include staff-appointed representatives.  

“The panel of the Global Board of Appeal (GBA) should have five-members,” stated the Staff Association. “A three-member panel – the current practice – is simply not reassuring staff that GBA deliberations are sufficiently robust,” the Staff Association letter stated.“Furthermore, the staff representatives on each of the GBA panels should be selected by the respective staff association rather than selected by the GBA Chair or Deputy-Chair.”  

The net result of the current system is that – short of a costly and lengthy appeal to the International Labour Organization – disciplinary cases are heard by a GBA board appointed by senior managers who report directly to Tedros, who also decides on the final outcome of the cases. 

With regards to the DRC cases, allegations that high-ranking WHO managers or consultants with ties to Tedros may have turned a blind eye to the reports of abuses going on in the field, have never been publicly resolved.  But the concerns extend beyond sexual harrassement, to the need to foster an institutional culture of professionalism free of political interference, critics also say, pointing to other episodes like the suppression of a 2020 WHO report on Italty’s pandemic response, which criticized another senior WHO advisor to Tedros. 

From a sustainable budget a sustainable planet?        

While WHO’s financial sustainability received considerable attention at this year’s WHA, there was comparatively little debate on the planet’s sustainability crisis – and how that may be fueling a cascading array of health impacts – from more noncommunicable diseases to emerging outbreaks, such as SARS-CoV2 and more recently a worldwide surge in monkeypox.   

A new roadmap to accelerate work on noncommunicable diseases fails to give more than a nod to air pollution as one of the leading causes of NCDs – responsible for some 7 million deaths a year from cancers, cardiovascular and lung diseases every year. And that doesn’t even include risks from chemicals exposures that make the total estimate of deaths from pollution closer to 9 million annually, according to a new Lancet Planetary Health Report released on 18 May.

In a debate over an NCD roadmap that aims to slash NCD risks by one third by 2030, France, speaking on behalf of some European Union member states,called for a more “integrated” approach that includes environmental health and climate change. 

So far, such approaches have been slow in coming. Despite the rhetoric about air pollution being a leading risk factor for NCDs, there are, as yet, no WHO “Best Buys” for environmental strategies that reduce deadly pollution risks – even if measures like clean public transport and compact cities, built around cycling and walking networks, are regarded by urban planners and transport managers as evidence-based solutions that have a record of demonstrated results.  

‘One Health’ and food safety – some new approaches

On the brigher side, a new WHO Global Strategy for Food Safety was approved by member states. For the first time ever, the strategy makes reference, at least in passing, to the need for a “One Health approach when addressing health risks emerging at the human-animal-ecosystems interface.”  

A companion decision asks WHO to also update its guidance on  Reducing public health risks associated with the sale of live wild animals of mammalian species in traditional food markets. 

Such guidance emerges out of the SARS-CoV2 pandemic, where peoples’ exposure to SARS-CoV2 infected animals in the Wuhan, China live animal market is considered to be one of the most plausible routes by which SARS-CoV2 initially leaped from animal to human populations in Wuhan, China during 2019.

But the caging and slaughter of live, wild animals in areas heavily trafficked by customers are practices common in thousands of traditional markets in Asia and Southeast Asia, as well as  parts of Africa, leading to further risks of human exposure to pathogens the animals may harbour.  

Not nearly enough action to stop pandemics at source

Such “One Health” issues need far more deliberate and systematic WHO and member state attention than the nod that they have so far, a growing chorus of “Ecohealth” experts say.

In a little-noticed press release issued during WHA, Dr Nigel Sizer, executive director of the consortium Preventing Pandemics at the Source called upon the WHA to do more to address ecosystem risks upstream that increase “spillover risks” of pathogen leap from animal to human populations: 

“Such actions include shutting down or strictly regulating wildlife trade and markets, stopping deforestation and forest degradation, and providing better health to communities in emerging infectious disease hotspots, as well as strengthened veterinary care and biosecurity in animal husbandry,” said Sizer, an internationally known conservationist,  in his statement. 

“Overall throughout the WHA process and in the preparations for negotiation of a possible global instrument on pandemic prevention and preparedness there has been remarkably little attention given to true pandemic prevention,” Sizer later told Health Policy Watch.  

“We know where most pandemics come from and we know how to reduce the risk of zoonotic spillover of the vruses that cause them,” he added. 

“Governments in general and health agencies in particular should embrace these approaches, including One Health efforts.  They should also work much more closely with environmental agencies to address spillover risk from tropical deforestation, wildlife exploitation and trade, and intensive animal agriculture. The public health return on investment in such activities would be enormous.”

Health and Environment: WHO structures preserve a deep divide  

There are parallel calls to better incorporate such concerns into any future “pandemic instrument” intended to have a broader scope than the International Health Regulations, and to be the focus of intense negotiations by a WHA Intergovernmental Board (INB) in coming months.  

However, the yawning chasm environmental groups encounter in trying to to interact with WHO and WHO member states over environmental health and One Health concerns, can sometimes appear as wide as the divide between member states on the terms around sexual health.   

“It has been exceedingly difficult to engage with the WHA or with the intergovernmental negotiating body’s (INB) process to draft and negotiate a new pandemic instrument,” Christine Franklin, of the Wildlife Conservation Society, another member of the Preventing Pandemics coalition, told Health Policy Watch. 

The club of non-state actors in ‘official relations’

“Only non-State actors in official relations with the WHO are invited to engage with the WHA,” she remarked.

That status of ‘official relations’ not only allows civil society groups the privilege of expounding on their positions at the annual World Health Assembly, it gives them access to lengthy and detailed informal member state consultations and intergovernmental negotiating sessions that are closed to the general public and the media. 

Some 220 civil society actors hold that coveted status, mostly mainstream medical and health societies as well as pharma groups, but also agro-business foundations, such as CropLife International, as well as the outliers like the World Plumbing Council. A review by Health Policy Watch found nary an environmental or eco-health group on the list, as of February 2022.  

“So even though Wildlife Conservation Society has been working across the globe for more than 125 years; is the only international conservation organization with an embedded health program, works on the ground in more than 60 countries; and our health program is recognized as a One Health founder and a leader at the nexus of health and the environment, the INB’s public hearing has been the only opportunity we have had to provide input,” Franklin lamented. 

“Oral testimonies were limited to two minutes and written statements restricted to 250 words. In fact, there are no organizations from the conservation or environment communities in official relations with the WHO and the process to gain status is complex and lengthy.” 

Image Credits: Germany's UN Mission in Geneva , WHO, Lancet Planetary Health, Nature , Pierce Mill Media, Wildlife Conservation Society .