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Photograph: Ed Jones/AFP/Getty
The long read
This article is more than 4 years old


THE WHO V CORONAVIRUS: WHY IT CAN'T HANDLE THE PANDEMIC

This article is more than 4 years old
Photograph: Ed Jones/AFP/Getty




Attacked by Trump and ignored by many of its most powerful members, the World
Health Organization is facing a major crisis – just at the moment we need it
most

By Stephen Buranyi
Fri 10 Apr 2020 07.00 CESTLast modified on Tue 29 Mar 2022 12.27 CEST
Share




If, like me, you have been confined to your home, glued to the news and nursing
ever greater anxiety about the state of the world, you have probably become
familiar with the sight of the World Health Organization’s director general,
Tedros Adhanom Ghebreyesus, and his daily press briefings. Tedros, as he is
known, is a calming presence in the midst of the crisis. Flanked by an
international cast of scientists, he always seems confident that if we have
hope, listen to the experts and pull together, we will get through this.

Watching this reassuring spectacle, it is possible to imagine a world in which
every nation respects the WHO’s authority, follows its advice and lets it
coordinate the flow of information, resources and medical equipment across
national boundaries to areas of greatest need.


The WHO v coronavirus: why it can't handle the pandemic – podcast
Read more

That is not the world we live in. “The W.H.O. really blew it. For some reason,
funded largely by the United States, yet very China centric,” tweeted Donald
Trump on 7 April, summing up just one of the many lines of criticism the WHO is
currently facing. It is not just Trump – even some of the WHO’s supporters in
government, academia and NGOs argue that since the start of the coronavirus
crisis, it has caved in to nationalist bullies, praised draconian quarantine
measures and failed to protect the liberal international order of which it is a
linchpin. “You’ve got a situation where it looks like WHO doesn’t want to
exercise its authority,” said David Fidler, a fellow in global health at the
Council on Foreign Relations and a regular consultant to the WHO.

Meanwhile, the WHO is desperately struggling to get its 194 member states to
actually follow its guidance. The WHO’s leaders are “very frustrated,” said John
MacKenzie, a virologist and adviser on the WHO’s emergency committee. “The
messages come out loud and clear, and some disregard the warnings. The US
largely did, the UK largely did.”

On 11 March, the day Tedros declared the coronavirus a pandemic, he spoke darkly
of “alarming levels of inaction” from many countries. Pressed by journalists to
name them, Mike Ryan, the usually no-nonsense Irish trauma doctor who heads the
WHO’s Covid-19 response, demurred. “You know who you are,” he said, adding that
“we don’t criticise our member states in public”.

View image in fullscreen
Donald Trump at a coronavirus task force briefing at the White House.
Photograph: Chip Somodevilla/Getty Images

There is a simple reason for this. For all the responsibility vested in the WHO,
it has little power. Unlike international bodies such as the World Trade
Organization, the WHO, which is a specialised body of the UN, has no ability to
bind or sanction its members. Its annual operating budget, about $2bn in 2019,
is smaller than that of many university hospitals, and split among a dizzying
array of public health and research projects. The WHO is less like a military
general or elected leader with a strong mandate, and more like an underpaid
sports coach wary of “losing the dressing room”, who can only get their way by
charming, grovelling, cajoling and occasionally pleading with the players to do
as they say.

The WHO “has been drained of power and resources”, said Richard Horton, editor
of the influential medical journal the Lancet. “Its coordinating authority and
capacity are weak. Its ability to direct an international response to a
life-threatening epidemic is non-existent.”

At the same time, the international order on which the WHO relies is fraying, as
aggressive nationalism becomes normalised around the world. “All the previous
rules about global norms, public health and understanding of what’s expected in
terms of an outbreak has crumbled,” said Lawrence Gostin, director of the WHO
Collaborating Center on National and Global Health Law. “None of us know where
this is leading.”

--------------------------------------------------------------------------------

The WHO was born during the moment of hopeful internationalism that followed the
chaos of the second world war. The idea of global collaboration in fighting
disease was not new – in the 19th century, at periodic International Sanitary
Conferences, countries had standardised quarantine procedures for cholera and
yellow fever – but the WHO constitution, adopted in 1948, envisioned a far
grander global mission, nothing less than “the attainment by all people of the
highest possible levels of health”.

One of the WHO’s favourite success stories is the role it played in eliminating
smallpox, a disease that was still killing millions each year in the 50s,
despite the existence of a vaccine. Although the WHO worked on immunisation
research, its most vital role was organisational and diplomatic. In 1959, it
convinced the Soviet Union to manufacture 25 million vaccine doses, which the
WHO would distribute. Not to be left behind, the US donated millions of dollars
to vaccination programmes, both directly and through the WHO. By the late 60s,
every nation in the UN was sending a detailed weekly report to WHO headquarters
on their number of smallpox cases and recent progress. And in 1979, WHO declared
smallpox eradicated, a first in world history. The WHO didn’t provide the most
money, immunise the most people, or invent key technologies such as the
bifurcated needle, but it is hard to imagine smallpox having been defeated
without it.

View image in fullscreen
Posters of WHO chief Tedros Adhanom in Sao Paulo, Brazil last week. Photograph:
Fernando Bizerra Jr/EPA

If the story of smallpox eradication shows the WHO acting as something like an
international ministry of public health, it doesn’t explain its current position
as an emergency service, surveying the world for disease outbreaks and springing
into action to contain them. That is a more recent addition to its portfolio,
which came after a period, in the 80s and 90s, when the WHO seemed to be losing
its earlier dynamism. The diseases it was partly created to address – smallpox,
yellow fever and the plague – had either been eradicated or were in decline, and
it was slow to identify new threats such as HIV/Aids. Under the leadership of Dr
Hiroshi Nakajima, from 1988 to 1998, the organisation stagnated, and some member
states complained about poor management and alleged petty corruption.

Two things happened at the turn of the century that would shape the WHO we now
see tackling the Covid-19 crisis. In 1998, the fiery former prime minister of
Norway, Dr Gro Harlem Brundtland, was elected director general. And in 2002, a
farmer in China’s Guangdong province became sick with a deadly,
never-before-seen respiratory disease that quickly spread among the hospital
staff who had treated him, and went on to become the first pandemic of the newly
globalised 21st century: one that arose suddenly, had no treatment or cure, and
spread with the speed and reach of international business.

--------------------------------------------------------------------------------

Given the WHO’s sprawling structure, vague mandate and reliance on diplomacy,
its director general holds immense power to shape it. Even before she took on
the role, Brundtland was comfortable on the world stage. “I was already a
political leader, and I was used to this kind of authority,” she told me. Like
her friend Kofi Annan, the charismatic UN leader, Brundtland believed that
international bodies should be prepared to lead when necessary, rather than
being bossed around by powerful nations. “If the job is to direct and coordinate
global health, it’s not a question of what one or several governments ask you to
do,” she said. “We are working for humanity.”

Brundtland pushed the WHO to use its local contacts, diplomatic channels and the
emerging internet to locate potential outbreaks, all of which made the
organisation less reliant on national governments for information. Within just a
few years, this strategy proved its worth. In November 2002, when the Chinese
government became aware of the first cases of a novel respiratory disease, later
named Sars, it failed to alert the WHO. But, as part of Brundtland’s new
approach, WHO staff were monitoring Chinese medical message boards and news
media anyway, and were aware of what was then thought to be an atypical
pneumonia outbreak. Adding to their suspicions, on 10 February 2003, David
Heymann, who was then executive director of the WHO’s communicable diseases
cluster, received an email from the son of a former WHO staff member in China
warning of a “strange contagious disease” that had already killed 100 people,
but which was “not allowed to be made known to the public”. The WHO took the
information it had to China, which made its first official report to the WHO the
next day.

View image in fullscreen
WHO director-general Gro Harlem Brundtland (centre) gives polio immunisation to
a young boy in New Delhi in January 2000. Photograph: John Mcconnico/AP

Although the WHO had no formal powers to monitor and censure its members,
Brundtland wasn’t shy about doing so anyway. In the ensuing months she would
accuse China of withholding information, claiming that the outbreak might have
been contained “if the WHO had been able to help at an earlier stage” and
exhorting the Chinese to “let us come in as quickly as possible!” With
remarkable speed, China fell in line and shared its data with the WHO. “After
her statements to China, no other countries hesitated,” said Heymann.

In March 2003, as the disease spread – reaching Hong Kong, Vietnam and then
Canada – for the first time in its history, the WHO issued advice against
travelling to affected areas. (Before then, the decision to advise on travel had
always been left up to member states.) Despite having no formal powers to ground
planes, the measures worked. “Passengers and flights dropped dramatically as
soon as we issued the recommendations,” said Heymann.

Brundtland’s approach was not always popular, and some bridled under this new
upstart WHO. “It wasn’t just China,” Brundtland told me. “The mayor of Toronto
[Mel Lastman] flew to Geneva to tell us take down the travel recommendation –
while at the same time he was not containing the outbreak. He had people with
Sars riding around the subway, no contact tracing, no following up. He couldn’t
accept we were telling him what to do!”

The WHO’s response to Sars was considered a huge success. Fewer than 1,000
people worldwide died of the disease, despite it reaching a total of 26
countries. The pandemic was defeated not with vaccines or medicines, but with
NPIs, or “non-pharmaceutical interventions” in WHO parlance: travel warnings,
tracking, testing and isolating cases, and a huge information-gathering
operation across multiple countries, all made possible by the WHO’s willingness
to wield authority that it had, in a sense, created simply by speaking it into
existence. “Brundtland did things the WHO had no authority doing. She just did
them,” said Fidler. “She sort of used Sars as a way to test drive some very
radical changes.”

“After Sars, the WHO’s position was essentially: that was great, let’s formalise
it,” said Clare Wenham, a professor of global health policy at LSE. In 2005, the
WHO drew up a new version of the International Health Regulations (IHR), the
central legal document that all member states are bound by. According to Fidler,
the updated IHR, which is in force to this day, is a radical document. It asks
its members to prepare for public health threats according to standards set by
the WHO, and to report any outbreaks and all subsequent developments. It also
allows the WHO to declare a public health emergency of international concern (or
PHEIC, pronounced, incredibly, “fake”), using its own information, over the
objection of any single country. During an emergency, countries are expected to
take the lead from the WHO’s guidelines and report any deviations to the
organisation. All of these requirements, bar the reporting of outbreaks, were
new.

But the document stopped short of giving the WHO real power if states refuse to
comply. “The WHO isn’t Nato, it’s not the security council,” said Gian Luca
Burci, who was the WHO’s legal counsel until 2018. The US, fixated on
bioterrorism after 9/11, supported giving the organisation some extended powers,
but was opposed by Brazil, Russia, India and China, which were wary of US
influence. There was a general reluctance to hand an international organisation
any more power. “WHO members were happy with the actions that were taken during
Sars, but there was definitely a sense afterward of ‘What if that was us in
China’s spot?’,” explained Catherine Worsnop, a professor at the University of
Maryland School of Public Policy. In short: thanks for stopping the pandemic,
but we don’t want to be told what to do.

--------------------------------------------------------------------------------

If the WHO has seemed at times weak or tentative – very un-Brundtland-like – in
its handling of the coronavirus crisis, it is partly because of its bruising
experiences during the past decade. From 2009 onwards, the WHO faced
condemnation from the press and the international community for its handling of
successive crises, all during a decade when the financial and diplomatic order
that sustained it began to break down.

First, there was the outbreak of H1N1, or “swine flu”. The novel influenza virus
was discovered in Mexico in March 2009, and by June, when the WHO declared a
pandemic, there were more than 28,000 cases in 74 countries. Over the next year,
the WHO coordinated the global response – less aggressively than during Sars –
and on 10 August 2010, it declared the pandemic over. Almost immediately, the
WHO’s approach came under scrutiny. The death toll – 18,500 confirmed deaths
worldwide – was far lower than initially expected, particularly given the
disease reached more than 200 countries. “Suddenly you have people saying: ‘Wait
a minute, you really cried wolf on this,’” says Wenham. The media and several
prominent European politicians demanded inquiries as to whether the WHO had
mistakenly rung the alarm, and “cost huge amounts of money and frightened people
unnecessarily”, as Paul Flynn, the former Labour MP who chaired one of the
inquiries, told the Times in 2010.

To this day, opinions are split as to whether H1N1 was a crisis headed off, or a
false alarm. “The WHO is always at risk of being criticised as doing too much or
too little,” said Keiji Fukuda, the former WHO assistant director general who
led the H1N1 response. Most of the former WHO staff and academics I spoke with
agreed, proposing some version of the following as an iron law of public health:
act slowly and you will be criticised for failing to stop preventable deaths;
act aggressively and stop an outbreak before it becomes serious, and you will be
accused of having overreacted. (After all, in the latter case, nothing too bad
happened, so what was the big deal in the first place?)

Fidler, who largely approves of WHO’s quick action during H1N1, believes that
the backlash led the WHO, which was then under the command of director general
Margaret Chan, to become too tentative about calling for action in the future.
This was a period when the fallout from the 2008 financial crisis was also
starting to take its toll on its budget. “There was a big funding shortfall,”
said Andrew Cassels, director of strategy at the WHO between 2008 and 2013.
“Cuts made to the emergency response programmes, personnel cuts.” The funding
gap stood at nearly $300m in 2012. Entire offices were shut, including a team of
social scientists working on pandemic response.

View image in fullscreen
WHO staff training nurses to use protective gear in Freetown, Sierra Leone
during the 2014 ebola outbreak. Photograph: Michael Duff/AP

When the Ebola outbreak struck west Africa in 2014, the combination of the WHO’s
greater caution and reduced budget resulted in disaster. In contrast to the
previous pandemic, this time the WHO was slow to act, and was widely perceived
to have lost control of the situation. In the end, the US and several other
nations deployed more than 5,000 military personnel at the request of the
affected countries, and an ad-hoc UN committee was created to take over
responsibilities from the WHO. The outbreak eventually killed 11,310 people, the
vast majority in just three countries – Guinea, Liberia and Sierra Leone –
paralysing their health systems for months, and causing panic across the world.
Prominent scientists judged the WHO’s response an “egregious failure”.

Much of the blame fell on Chan herself. She appeared shell-shocked, stressing to
the press that the WHO was a technical advisory body, and that it was national
governments that had ultimate responsibility for their citizens’ health. “She
wanted the WHO to be an apolitical agency – more like technical support. There
was a hesitancy there to push the full powers of the WHO,” said Sara Davies, a
professor of global health at Griffith University in Australia.

The bold, proactive culture established after Sars had seemingly faded. Fidler
believes that by delaying calling Ebola an emergency, and thus failing to
organise an international response at a crucial moment, the WHO’s leadership had
shown they “no longer had any faith in their authority”.

--------------------------------------------------------------------------------

Today, under Tedros, the WHO finds itself in uncharted territory. Not only is it
facing by far the biggest pandemic in its history, it is also having to defend
itself from the nations on which it most depends. “In my 25-plus years of
working on global health issues, I cannot recall the leader of a prominent
developed country threatening to punish WHO in the manner President Trump did,”
said Fidler, referring to the recent press conference in which Trump suggested
putting “a very powerful hold” on US contributions to the WHO. In the same press
conference, Trump accused the WHO of concealing information, being too slow to
react to the virus, and, above all, showing favouritism towards China.

Since the crisis began, Tedros has been repeatedly accused of being soft on
China. Senator Marco Rubio recently told Fox News that the Chinese government
had “used the WHO to mislead the world”, and claimed that the WHO “is either
complicit or dangerously incompetent”. The US senator Rick Scott put it more
bluntly, accusing the WHO of “helping Communist China cover up a global
pandemic”. (Tedros, meanwhile, has warned of the dangers of politicising the
virus.)

Until very recently, the WHO was seen as a relatively neutral arena for China to
extend its power. “China likes to find ways within the global system to give it
a leading and benevolent image. The WHO was an uncontroversial place to do it,”
said Rana Mitter, the director of the University of Oxford China Centre. No
longer. The extent of the initial coverup is still unclear, but there is no
question that at least at the local level, Chinese officials knew about the
outbreak of a novel disease for weeks before it was reported to the WHO. During
that time, Chinese doctors were prevented from speaking out.

John MacKenzie, the WHO’s emergency committee adviser, told me that the
organisation was “a little misled” about the Wuhan outbreak. He says that by the
time the government alerted the WHO on 31 December, scientists in China had
already determined via genome sequencing that the outbreak was caused by
coronavirus. Yet the government didn’t confirm that until 7 January and the full
genome sequence was not officially shared until 12 January. “That’s very slow,”
MacKenzie told me. “For at least two weeks, we could have been making far more
kits and so on for testing.” MacKenzie added that the number of cases officially
declared by the Chinese in the first week – 59 in the week ending 5 January –
was “nowhere near as many cases as you’d expect”. (The statistics released by
the Chinese government continue to be questioned, with some reports suggesting
they may have seriously understated the number of coronavirus deaths.)

Despite mounting frustrations – in mid-January, China also refused the WHO’s
request to send a team of scientific observers to Hubei province, the centre of
the outbreak – Tedros has never come close to doing what Brundtland did and
calling China out. Instead, on 28 January, he had a closed-door meeting with Xi
Jinping in Beijing, and two days later, he praised Chinese efforts to contain
the disease, declaring that China is “setting a new standard for outbreak
control”. That same day, 30 January, the WHO declared a Pheic, and began issuing
prescriptions to countries around the world. On 8 February, China finally
allowed WHO observers into the country. For Tedros’s supporters, this was
vindication of his strategy of keeping China onside. For his critics, it was too
little, too late.

View image in fullscreen
WHO director-general Adhanom Ghebreyesus with Chinese President Xi Jinping in
Beijing on 28 January 2020. Photograph: Naohiko Hatta/AFP via Getty Images

Elected as WHO director general in July 2017, Tedros was supported by a bloc of
African and Asian countries, including China, which has considerable influence
with those members. (Tedros is himself from Ethiopia, where he served as health
minister and then foreign minister between 2005 and 2016.) It was a “really
nasty” election, said Davies, in which the powers that have traditionally shaped
the WHO, such as the US, UK and Canada, lent their support to one of Tedros’s
rivals, the British doctor David Nabarro. During the campaign, Tedros was
criticised for having served in a repressive government with a poor human rights
record, and one of Nabarro’s backers even accused Tedros of covering up a
cholera epidemic during his time as health minister. (Tedros denied the claim,
describing it as a “last-minute smear campaign”, while Nabarro told the New York
Times that he had never authorised his team to make this accusation against
Tedros.) In response, Tedros’s supporters mounted “a collective pushback”, said
Davies, against the UK and its allies, eventually winning out. Tedros became the
first director general from a so-called developing country since the Brazilian
Dr Marcolino Gomes Candau in 1953.

While his background is in politics, Tedros is not forthright or confrontational
like Brundtland. In Ethiopia, his political party, the Tigray People’s
Liberation Front (TPLF) was mostly comprised of ex-revolutionaries, men that
“seemed carved out of a rock”, said Fantu Cheru, a professor at American
University and former advisor to the Ethiopian government. Tedros was different
– jovial and accessible, said Cheru, and able to make personal connections
easily. “He is not very ideological, he believes he can work with anyone,” said
Mehari Taddele Maru, a professor at the European University Institute in
Florence, Italy. Cheru also sees Tedros as a pragmatist. “He’s not in the
Chinese pocket. The Americans in particular wanted to destroy his image. Tedros
knows how this game works. You need to have more allies than enemies, and those
allies may not have a good track record.”

“I don’t think Tedros did anything previous director generals would not have
done,” said Anthony Costello, the director of the UCL Institute for Global
Health. “He needed a good relationship with China in order to get in.” Even
Lawrence Gostin, who has been a prominent critic of Tedros in the past, told me
that “his high praise for China is understandable. He is seeking to coax China
into cooperation.” He went on to note, though, that this strategy “does risk the
credibility of WHO as an objective agency.”

If the WHO thought it could sacrifice a bit of its credibility – overlooking
China’s obvious blunders in December and January in exchange for its compliance
in February – and move on, it was mistaken. The argument over China’s influence
has been raging for weeks, not least since the government of Taiwan claimed that
the WHO had ignored its own early reports of human-to-human transmission of
coronavirus as part of a larger history of appeasing China – which has blocked
Taiwan from joining the WHO (and the UN) for decades.

Now that Trump, scrambling for an answer to explain why the US now has more
cases of coronavirus than any other nation, has alighted upon the WHO and China
as his preferred scapegoats, these questions will not go away. “I don’t think we
will see the US government cut off funding,” said Fidler. “But what’s happened
with this pandemic – with the WHO caught between the US/China rivalry – is not a
good omen for the WHO going forward.”

--------------------------------------------------------------------------------

While the focus has been on what happened between China and the WHO in January,
in epidemiological terms the crisis has moved on. Covid-19 has spread fastest
and furthest in the US and Europe, through the very rich nations that largely
fund and staff the WHO. Before the outbreak, the WHO struggled to get these same
nations to prepare for future pandemics. Now the pandemic is here, and they are
at the centre of the crisis, the WHO has been unable to keep them following its
advice.

Richard Horton of the Lancet said that after the WHO declared a public health
emergency, “countries, especially western countries, didn’t listen. Or didn’t
seek to understand what was actually taking place in China.” On 5 February, the
WHO asked for $675m to fund its Coronavirus response through to April. Anthony
Costello of UCL said that when he met with Tedros on 4 March, the WHO had
received only $1.2m. (Tedros announced last week that the funding goal had
finally been reached, around the time the number of worldwide cases passed 1
million.)

Even the decision to declare a pandemic on 13 March – a largely rhetorical
distinction, since calling a Pheic already requires WHO members to respond – was
calculated to wake its member states up. In the UK the Premier League was still
playing games, and the previous week the US had held primary election contests.
“They declared a pandemic because countries weren’t taking the advice,” said
Adam Kamradt-Scott, a professor of global health at the University of Sydney.

The WHO stresses that the ideal response to the crisis is relatively simple.
Individual states should limit public exposure, especially by tracking and
tracing all known cases – a strategy that worked in South Korea and appears to
be working in Germany. On an international level, states should share scientific
information and resources. These are the mantras Tedros goes back to in his
briefings: “Test test test” and “solidarity solidarity solidarity”.

But countries have repeatedly ignored WHO advice. In the UK, the response has
been erratic, lurching between the WHO’s norms and its own strategies, such as
the now-discredited pursuit of “herd immunity”. The US didn’t recommend school
closures or avoiding travel until 16 March. In Sweden, restaurants are still
open.

Many wealthy nations have not only pursued their own national strategies for
public health, but have also withdrawn from the globalised world of diplomacy
and trade that they themselves set up. Earlier this year, for instance, the NHS
ordered millions of masks from a French company named Valmy SAS. But in early
March, the French government requisitioned all masks produced within the
country, so the masks never reached Britain. This week, Germany accused the US
of seizing a shipment of masks bound for Berlin from a port in Thailand; while
Germany previously sent inspectors to the factory of an American company in
Jüchen to ensure their medical masks weren’t being exported against government
orders.

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The WHO is battling against a breakdown in international cooperation that is far
beyond its capacity to control. “Governments have retreated to national
policies, and this problem predates this crisis,” said Clare Wenham, the health
scholar. States have been turning away from international institutions for a
long time. The WHO hasn’t driven globalisation in the same way as the WTO or
IMF, but in a way it has administered it – quietly promising to take on the
outbreaks that arise in an industrialised and interconnected world, and relying
on the often unspoken norms of international collaboration that underlie it.

Ironically, it is most needed now, at a time when faith in the other
administrators and overseers of the global order are in decline – a trend that
Covid-19 only seems to be accelerating. “As it’s gone on, you see the WHO
becoming less important,” said Wenham. “No one is thinking about reducing the
global numbers, only their own. The WHO is a global force, but people aren’t
thinking globally.”

Follow the Long Read on Twitter at @gdnlongread, and sign up to the long read
weekly email here.

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