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mef, like me, you have been confined to your home, glued to the news and increasingly anxious for the state of the world, you have probably familiarized yourself with the sight of the director general of the World Health Organization, Tedros Adhanom Ghebreyesus, and their daily press reports. 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, we listen to the experts, and we unite, we will overcome it.
By watching this reassuring spectacle, it is possible to imagine a world in which each nation respects the authority of WHO, follows its advice, and enables it to coordinate the flow of information, resources, and medical equipment across national borders to the areas of greatest need.
That’s not the world we live in. “The W.H.O. Really blew it. For some reason, largely funded by the United States, but highly focused on China.” tweeted Donald Trump on April 7, summarizing just one of the many lines of criticism currently facing the WHO. It’s not just about Trump, even some of the WHO’s supporters in government, academia and NGOs argue that since the start of the coronavirus crisis, he has given in to nationalist thugs, praised draconian quarantine measures and failed to protect the international liberal order. It is a key piece. “There is a situation where it appears that the WHO does not want to exercise its authority,” said David Fidler, a global health member of the Council on Foreign Relations and a regular consultant to the WHO.
Meanwhile, WHO is desperately fighting to get its 194 member states to truly follow its lead. WHO leaders are “very frustrated,” said John MacKenzie, a virologist and advisor to the WHO emergency committee. “The messages come out loud and clear, and some ignore the warnings. The United States did a great deal, the United Kingdom did a great deal. “
On March 11, the day Tedros declared the coronavirus to be a pandemic, he spoke grimly of “alarming levels of inaction” in many countries. Pressed by reporters to name them, Mike Ryan, the typically traumatic Irish doctor who directs the WHO’s Covid-19 response, objected. “You know who you are,” he said, adding that “we don’t criticize our member states in public.”
There is a simple reason for this. Despite all the responsibility conferred on WHO, it has little power. Unlike international organizations like the World Trade Organization, the WHO, which is a specialized agency of the UN, does not have the capacity to compel or sanction its members. Its annual operating budget, around $ 2 billion in 2019, is smaller than that of many university hospitals, and is divided among a dizzying array of research and public health projects. The WHO is less like a military general or elected leader with a strong mandate, and more like a poorly paid sports coach who is wary of “losing the locker room,” who can only get away with enchanting, crawling, cajoling, and occasionally pleading with him. Players. do what they say
The WHO “has run out of power and resources,” said Richard Horton, editor of the influential medical journal The Lancet. “His authority and coordination capacity are weak. Their ability to lead an international response to a life-threatening epidemic is non-existent. “
At the same time, the international order on which the WHO is based is fraying, as aggressive nationalism is normalizing worldwide. “All of the above rules about global standards, public health and understanding what to expect in terms of an outbreak have crumbled,” said Lawrence Gostin, director of the WHO Collaborating Center on National and Global Health Law. “None of us know where this is leading.”
TThe WHO was born at the time of hopeful internationalism that followed the chaos of the Second World War. The idea of global collaboration in the fight against the disease was not new: in the 19th century, in the periodic International Health Conferences, the countries had standardized the quarantine procedures for cholera and yellow fever, but the WHO constitution, Adopted in 1948, it envisioned a much larger world mission, no less than “the achievement by all people of the highest possible levels of health.”
One of the WHO’s favorite success stories is the role it played in eliminating smallpox, a disease that still killed millions each year in the 1950s, despite the existence of a vaccine. Although WHO worked on immunization research, its most vital role was that of organization and diplomat. In 1959, he convinced the Soviet Union to manufacture 25 million doses of vaccines, which the WHO would distribute. Not to be outdone, the United States donated millions of dollars to vaccination programs, both directly and through WHO. In the late 1960s, all UN nations sent a detailed weekly report to WHO headquarters on their number of smallpox cases and recent progress. And in 1979, the WHO declared smallpox eradicated, the first in world history. The WHO did not provide the most money, immunized most people, or invented key technologies such as the forked needle, but it is hard to imagine that smallpox would have been defeated without it.
If the history of smallpox eradication shows that the WHO acts as an international ministry of public health, it does not explain its current position as an emergency service, examining the world for disease outbreaks and acting to contain them. That’s a more recent addition to its portfolio, which came after a period, in the 1980s and 1990s, when WHO seemed to be losing its previous dynamism. The diseases for which it was created in part, smallpox, yellow fever and plague, had been eradicated or were declining, and he was slow to identify new threats such as HIV / AIDS. Under the leadership of Dr. Hiroshi Nakajima, from 1988 to 1998, the organization stalled, and some member states complained of mismanagement and alleged minor corruption.
Two things happened at the turn of the century that would shape the WHO we now see addressing the Covid-19 crisis. In 1998, the ardent former Prime Minister of Norway, Dr. Gro Harlem Brundtland, was elected CEO. And in 2002, a farmer in China’s Guangdong province fell ill with a deadly and never-before-seen respiratory disease that spread rapidly among hospital staff who had treated him and became the first newly globalized 21st century pandemic: one It emerged suddenly, had no treatment or cure, and spread with the speed and scope of international business.
SunGiven WHO’s expanding structure, vague mandate, and reliance on diplomacy, its Director-General has immense power to shape it. Even before taking on the role, Brundtland was comfortable on the world stage. “I was already a political leader, and I was used to this type 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 controlled by powerful nations. “If the job is to lead and coordinate global health, it’s not about what one or more governments are asking you to do,” he said. “We are working for humanity.”
Brundtland pressured WHO to use its local contacts, diplomatic channels and the emerging Internet to locate potential outbreaks, making the organization less dependent on national governments for information. In a few years, this strategy proved its worth. In November 2002, when the Chinese government learned of the first cases of a new respiratory disease, later called Sars, it did not alert WHO. But, as part of Brundtland’s new approach, WHO staff were monitoring Chinese medical message boards and the media anyway, and were aware of what was then thought to be an outbreak of atypical pneumonia. In addition to his suspicions, on February 10, 2003, David Heymann, who was then the executive director of the WHO communicable diseases group, received an email from the son of a former WHO staff member in China warning him of a ” strange contagious disease “that had already killed 100 people, but” was not allowed to go public “. The WHO brought the information it had to China, which made its first official report to the WHO the next day.
Although the WHO had no formal powers to monitor and censor its members, Brundtland had no qualms about doing so anyway. In the following months, he would accuse China of withholding information, claiming that the outbreak could have been contained “if the WHO had been able to help at an earlier stage” and urging the Chinese to “let us in as quickly as possible.” With remarkable speed, China aligned and shared its data with WHO. “After his statements to China, no other country hesitated,” Heymann said.
In March 2003, when the disease spread, reaching Hong Kong, Vietnam, and then Canada, for the first time in its history, the WHO issued advice against travel to affected areas. (Before that, the decision to advise on travel had always been left to the Member States). Despite having no formal powers to land planes, the measures worked. “Passengers and flights dropped dramatically as soon as we issued the recommendations,” Heymann said.
Brundtland’s approach was not always popular, and some dwindled under this emerging new WHO. “It wasn’t just China,” Brundtland told me. “The Mayor of Toronto [Mel Lastman] He flew to Geneva to tell us to remove the travel recommendation, while at the same time not containing the outbreak. I had people with Sars riding the subway, no contact tracking, no tracking. He couldn’t accept that we were telling him what to do! “
The WHO response to Sars was considered a great success. Fewer than 1,000 people worldwide died from the disease, despite reaching a total of 26 countries. The pandemic was defeated not with vaccines or drugs, but with NPI or “non-pharmaceutical interventions” in the WHO language: travel warnings, follow-up, testing and isolation of cases, and a large information gathering operation in several countries, all made possible by the will of WHO to exercise the authority that, in a sense, it had created simply by saying it existed. “Brundtland did things that the WHO had no authority to do. She just made them, “said Fidler. “She used Sars as a way to test some very radical changes.”
“After Sars, the WHO position was essentially: That was great, let’s formalize it,” said Clare Wenham, professor of global health policy at LSE. In 2005, WHO produced a new version of the International Health Regulations (IHR), the central legal document to which all member states are bound. According to Fidler, the updated RSI, which is in force to this day, is a radical document. It asks its members to prepare for threats to public health in accordance with the standards established by the WHO, and to report any outbreaks and all subsequent developments. It also allows WHO to declare a public health emergency of international concern (or PHEIC, pronounced, incredibly, “false”), using its own information, on any country’s objection. During an emergency, countries are expected to take the lead on WHO guidelines and report any deviations to the organization. All of these requirements, except notification of outbreaks, were new.
But the document failed to give WHO real power if states refuse to comply. “The WHO is not NATO, it is not the security council,” said Gian Luca Burci, who was WHO’s legal adviser until 2018. The United States, obsessed with bioterrorism after September 11, supported giving the organization some powers extended, but it was with the opposition of Brazil, Russia, India and China, who distrusted the American influence. There was a general reluctance to give an international organization more power. “WHO members were happy with the actions that were taken during Sars, but there was definitely a sense after ‘What if we were in the place of China?'” Explained Catherine Worsnop, professor at the Faculty of Public Policy from the University of Maryland. Bottom line: thanks for stopping the pandemic, but we don’t want to be told what to do.
meIf the WHO sometimes seems weak or tentative, very unlike Brundtland, in its management of the coronavirus crisis, it is partly due to its experiences with bruising over the past decade. Beginning in 2009, 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 supported it began to crumble.
First, there was an H1N1 outbreak, or “swine flu.” The new influenza virus was discovered in Mexico in March 2009, and in June, when the WHO declared a pandemic, there were more than 28,000 cases in 74 countries. During the following year, the WHO coordinated the global response, less aggressively than during Sars, and on August 10, 2010 declared the pandemic. Almost immediately, WHO’s approach came under scrutiny. The death toll (18,500 confirmed deaths worldwide) was much lower than initially expected, particularly given that the disease reached more than 200 countries. “You suddenly have people who say, ‘Wait a minute, you really cried wolf for this,'” Wenham says. The media and several prominent European politicians demanded questions about whether the WHO had mistakenly raised the alarm and “cost enormous amounts of money and unnecessarily scared people,” as said Paul Flynn, the former Labor MP who presided over one of the research. Times in 2010.
To this day, opinions are divided on whether H1N1 was a crisis or a false alarm. “WHO always runs the risk of being criticized for doing too much or too little,” said Keiji Fukuda, a former WHO deputy director-general who led the response to H1N1 flu. Most of the WHO staff and academics I spoke with agreed and proposed a version of the following as an iron law on public health: act slowly and you will be criticized for not stopping preventable deaths; Act aggressively and stop an outbreak before it becomes serious, and you will be accused of overreacting. (After all, in the last case, nothing bad happened, so what was the big problem in the first place?)
Fidler, who strongly approves of WHO’s swift action during H1N1, believes that the backlash led the WHO, then under the command of Director-General Margaret Chan, to be too tentative to call for action in the future. . This was a period in which the consequences of the 2008 financial crisis also began to affect its budget. “There was a huge funding gap,” said Andrew Cassels, WHO chief strategy officer between 2008 and 2013. “Cuts in emergency response programs, cuts in staff.” The funding gap was nearly $ 300 million in 2012. Entire offices were closed, including a team of social scientists working in response to the pandemic.
When the Ebola outbreak hit West Africa in 2014, the combination of increased caution and a reduced WHO budget resulted in disaster. Unlike the previous pandemic, this time the WHO was slow to act and it was widely perceived that it had lost control of the situation. In the end, the USA USA And several other nations deployed more than 5,000 military personnel at the request of affected countries, and an ad-hoc UN committee was created to assume WHO’s responsibilities. The outbreak killed 11,310 people, the vast majority in just three countries, Guinea, Liberia and Sierra Leone, paralyzing their health systems for months and causing panic worldwide. Prominent scientists judged the WHO response as a “heinous failure.”
Much of the blame fell on Chan herself. She seemed shocked, emphasizing to the press that WHO was a technical advisory body and that it was the national governments that had ultimate responsibility for the health of their citizens. “She wanted WHO to be a non-political agency, more like technical support. There was a hesitation to push the full powers of the WHO, “said Sara Davies, professor of global health at Griffith University in Australia.
The bold and proactive culture established after Sars had apparently vanished. Fidler believes that by delaying calling Ebola an emergency, and therefore by failing to mount an international response at a crucial time, the WHO leadership had shown that “they no longer had faith in their authority.”
TToday, under Tedros, the WHO is in unknown territory. Not only is it facing the largest pandemic in its history, but it also has to defend itself against the nations on which it depends most. “In my more than 25 years of working on global health issues, I cannot recall the leader of a prominent developed country threatening to punish the WHO the way President Trump did,” said Fidler, referring to the recent press conference in which Trump suggested putting “Very powerful control” over the contributions of the United States to the WHO. At the same press conference, Trump accused the WHO of hiding information, being too slow to react to the virus and, above all, showing favoritism 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 deceive the world,” and said that the WHO “is complicit or dangerously incompetent.” US Senator Rick Scott put it bluntly, accusing the WHO of “helping Communist China cover up a global pandemic.” (Tedros, meanwhile, has warned about the dangers of politicizing the virus.)
Until very recently, the WHO was viewed 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 undisputed place to do it, “said Rana Mitter, director of the China Center at Oxford University. No more. The scope of the initial cover-up is still unclear, but there is no doubt that at least locally, Chinese officials knew about the outbreak of a new disease for weeks before WHO was informed, during which time Chinese doctors were unable to speak.
John MacKenzie, the adviser to the WHO emergency committee, told me that the organization was “a bit misled” about the Wuhan outbreak. He says that when the government alerted the WHO on December 31, scientists in China had already determined by genome sequencing that the outbreak was caused by the coronavirus. However, the government did not confirm that until January 7, and the complete genome sequence was not officially shared until January 12. “That is very slow,” MacKenzie told me. “For at least two weeks, we could have been making many more kits, etc. for testing.” MacKenzie added that the number of cases officially declared by the Chinese in the first week, 59 in the week ending January 5, “is not as close to as many cases as might be expected.” (Statistics released by the Chinese government continue to be questioned, and some reports suggest they may have seriously underestimated the number of deaths from coronavirus.)
Despite mounting frustrations, in mid-January, China also rejected WHO’s request to send a team of scientific observers to Hubei province, the center of the outbreak, Tedros has never come close to doing what Brundtland did and call China. Instead, on January 28, he had a closed-door meeting with Xi Jinping in Beijing, and two days later, praised Chinese efforts to contain the disease, stating that China is “setting a new standard for outbreak control.” That same day, January 30, the WHO declared a Pheic and began issuing prescriptions to countries around the world. On February 8, China finally allowed WHO observers to enter the country. For Tedros’ supporters, this was a vindication of his strategy to keep China on track. To his critics, it was too little, too late.
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 from 2005 to 2016.) It was a “really nasty” election, said Davies, in which the powers that have traditionally shaped the WHO , like the United States. The United Kingdom and Canada lent their support to one of Tedros’ rivals, British physician David Nabarro. During the campaign, Tedros was criticized for having served in a repressive government with a poor human rights record, and one of Nabarro’s supporters 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 authorized his team to make this accusation against Tedros.) In response, Tedros’ supporters mounted “a collective setback,” Davies said, against the United Kingdom and its allies, ultimately winning. Tedros became the first CEO of a so-called developing country since Dr. Marcolino Gomes Candau in 1953.
Although his experience is political, Tedros is not frank or confrontational like Brundtland. In Ethiopia, its political party, the Tigray People’s Liberation Front (TPLF) was made up primarily of former revolutionaries, men who “looked like they were carved from a rock,” said Fantu Cheru, a professor at the American University and a former adviser to the Ethiopian government. . Tedros was different: jovial and approachable, Cheru said, and capable of making 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. “It is not in the Chinese pocket. The Americans in particular wanted to destroy their image. Tedros knows how this game works. You need to have more allies than enemies, and those allies may not have a good record.”
“I don’t think Tedros has done anything that previous CEOs haven’t done,” said Anthony Costello, director of the UCL Institute of Global Health. “I needed a good relationship with China to get in.” Even Lawrence Gostin, who has been a leading critic of Tedros in the past, told me that “his high praise for China is understandable. He is trying to convince China to cooperate. “However, he went on to point out that this strategy” risks WHO’s credibility as an objective agency. “
If the WHO thought it could sacrifice its credibility a bit, bypassing China’s obvious mistakes in December and January in exchange for its compliance in February, and moving on, it was wrong. The discussion of China’s influence has been raging for weeks, especially since the Taiwan government claimed that the WHO had ignored its own initial reports of person-to-person transmission of coronavirus as part of a broader story of appeasing China. , which has blocked Taiwan, joined the WHO (and the UN) for decades.
Now that Trump, seeking an answer to explain why the United States now has more cases of coronavirus than any other nation, has settled on WHO and China as his preferred scapegoats, these questions will not go away. “I don’t think we will see the US government cut the funds,” said Fidler. “But what happened with this pandemic, with the WHO caught between the rivalry between the United States and China, does not bode well for the WHO to move forward.”
WWhile the focus has been on what happened between China and the WHO in January, in epidemiological terms, the crisis has advanced. Covid-19 has spread faster and further in the United States and Europe, through the very wealthy nations that finance and staff WHO. Before the outbreak, WHO struggled to get these same nations to prepare for future pandemics. Now that the pandemic is here, and they are at the center of the crisis, WHO has been unable to keep them on their advice.
After The Lancet’s Richard Horton said that after the WHO declared a public health emergency, “countries, especially western countries, did not listen. Or did not try to understand what was really happening in China.” On February 5, the WHO requested $ 675 million to fund its response to the Coronavirus through April. UCL’s Anthony Costello said that when he met Tedros on March 4, the WHO had received just $ 1.2 million. (Tedros announced last week that the funding goal had finally been reached, around the time the number of cases worldwide exceeded one million.)
Even the decision to declare a pandemic on March 13, a largely rhetorical distinction, since calling a Pheic already requires WHO members to respond, was calculated to wake up its member states. In the United Kingdom, the Premier League was still playing, and the previous week the United States had held primary electoral contests. “They declared a pandemic because countries were not following the advice,” said Adam Kamradt-Scott, 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. At the international level, states should share scientific information and resources. These are the mantras to which Tedros returns in his informative sessions: “Test test test” and “solidarity solidarity solidarity solidarity”.
But countries have repeatedly ignored WHO’s advice. In the UK, the response has been erratic, ranging between WHO standards and their own strategies, such as the now-discredited quest for “collective immunity”. The United States did not recommend closing schools or avoiding trips until March 16. In Sweden restaurants are still open.
Many wealthy nations have not only followed their own national strategies for public health, but have also withdrawn from the globalized world of diplomacy and trade that they themselves established. Earlier this year, for example, the NHS ordered millions of masks from a French company called Valmy SAS. But in early March, the French government requisitioned all the masks produced within the country, so the masks never made it to Britain. This week, Germany accused the United States of confiscating a shipment of masks bound for Berlin from a port in Thailand; while Germany previously sent inspectors to the factory of a US company in Jüchen to ensure that its medical masks were not exported against government orders.
La OMS está luchando contra un colapso en la cooperación internacional que está mucho más allá de su capacidad de control. “Los gobiernos se han retirado a las políticas nacionales, y este problema es anterior a esta crisis”, dijo Clare Wenham, la académica de salud. Los estados se han alejado de las instituciones internacionales durante mucho tiempo. La OMS no ha impulsado la globalización de la misma manera que la OMC o el FMI, pero de alguna manera la ha administrado, prometiendo silenciosamente enfrentar los brotes que surgen en un mundo industrializado e interconectado, y confiando en las normas a menudo tácitas de colaboración internacional que lo subyace.
Irónicamente, es más necesario ahora, en un momento en que la fe en los otros administradores y supervisores del orden global está en declive, una tendencia que Covid-19 solo parece estar acelerándose. “A medida que avanza, ves que la OMS se vuelve menos importante”, dijo Wenham. “Nadie está pensando en reducir los números globales, solo los suyos. La OMS es una fuerza global, pero la gente no piensa globalmente “.
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