The Outbreaks That Never Happened and the Unseen Success of Global Institutions

Given all the death and dysfunction resulting from the COVID-19 pandemic, it is worth appreciating the many potential outbreaks that never happened, thanks to the efforts of Kenya, Mozambique, and Niger, alongside the United Nations and other international partners

In December 2019, just months before the COVID-19 pandemic came in full swing, these nations managed to halt an outbreak of a rare strain of “vaccine-derived polio”, which occurs “where overall immunization is low and that have inadequate sanitation, leading to transmission of the mutated polio virus”. It is all the more commendable given that Niger is among the ten poorest countries in the world.

The fact that polio remains both rare and relatively easy to quash is the results of a U.N.-backed campaign announced in 2005 to immunize 34 million children from the debilitating disease, which often leaves victims permanently disabled. The effort was led by  by World Health Organization the U.N. Children’s Fund (UNICEF), Rotary International, and the United States Centers for Disease Control and Prevention.

A nurse administers an oral poliovirus vaccine (OPV) to a baby at the Kaloko Clinic, Ndola, Zambia.
© UNICEF/Karin Schermbrucke

A little over fifteen years later, two out of three strains of polio have been eradicated—one as recently as last year—while the remaining strain is in just three countries: Afghanistan, Nigeria, and Pakistan. This once widespread disease is on its way to becoming only the second human disease to be eradicated, after smallpox, which once killed tens of millions annually. That feat, accomplished only in 1979, was also a multinational effort led by the U.N., even involving Cold War rivals America and Russia.

Even now, the much-maligned WHO actively monitors the entire world for “acute public health events” or other health emergences of concern that could portend a future pandemic. As recently as one month ago, the U.N. agency issued an alert and assessment concerning cases of MERS-Cov (a respirator illness related to COVID-19) in Saudi Arabia. Dozens of other detailed reports have been published the past year through WHO’s “Disease Outbreak News” service, spanning everything from Ebola in Guinea to “Monkeypox” in the United States. (WHO also has an influenza monitoring network spanning over half the world’s countries, including the U.S.).

Not bad for an agency with an annual budget of slightly over two billion—smaller than many large U.S. hospitals. (And contrary to popular belief in the U.S., the WHO did in fact move relatively quickly with respect to the COVID-19 pandemic:

On 31 December 2019, WHO’s China office picked up a media statement by the Wuhan Municipal Health Commission mentioning viral pneumonia. After seeking more information, WHO notified partners in the Global Outbreak Alert and Response Network (GOARN), which includes major public health institutes and laboratories around the world, on 2 January. Chinese officials formally reported on the viral pneumonia of unknown cause on 3 January. WHO alerted the global community through Twitter on 4 January and provided detailed information to all countries through the international event communication system on 5 January. Where there were delays, one important reason was that national governments seemed reluctant to provide information

Of course, it goes without saying that the WHO, and global institutions generally, have their shortcomings and failings (as I previously discussed). But much of that stems from structural weaknesses imposed by the very governments that criticize these international organizations in the first place:

WHO also exemplifies the reluctance of member states to fully trust one another. For example, member states do not grant WHO powers to scrutinise national data, even when they are widely questioned, or to conduct investigations into infectious diseases if national authorities do not agree, or to compel participation in its initiatives. Despite passing a resolution on the need for solidarity in response to covid-19, many member states have chosen self-centred paths instead. Against WHO’s strongest advice, vaccine nationalism has risen to the fore, with nations and regional blocks seeking to monopolise promising candidates. Similarly, nationalistic competition has arisen over existing medicines with the potential to benefit patients with covid-19. Forgoing cooperation for selfishness, some nations have been slow to support the WHO organised common vaccine development pool, with some flatly refusing to join.

The tensions between what member states say and do is reflected in inequalities in the international governance of health that have been exploited to weaken WHO systematically, particularly after it identified the prevailing world economic order as a major threat to health and wellbeing in its 1978 Health for All declaration. WHO’s work on a code of marketing of breastmilk substitutes around the same time increased concern among major trade powers that WHO would use its health authority to curtail private industry. Starting in 1981, the US and aligned countries began interfering with WHO’s budget, announcing a policy of “zero growth” to freeze the assessed contributions that underpinned its independence and reorienting its activities through earmarked funds. The result is a WHO shaped by nations that can pay for their own priorities. This includes the preference that WHO focus on specific diseases rather than the large social, political, and commercial determinants of health or the broad public health capacities in surveillance, preparedness, and other areas needed for pandemic prevention and management

In fact, it was this prolonged period of chronic underfunding, and of WHO member states prioritizing nonemergency programs, that precipitated the agency’s abysmal failings in the early phases of the 2014 Ebola outbreak. But once that crisis ended, member states, rather than defund or abandon the organization, opted to reform and strengthen its emergency functions; this overhaul resulted in the Health Emergencies Program, which was tested by the pandemic and thus far proven relatively robust:

On 31 December 2019, WHO’s China office picked up a media statement by the Wuhan Municipal Health Commission mentioning viral pneumonia. After seeking more information, WHO notified partners in the Global Outbreak Alert and Response Network (GOARN), which includes major public health institutes and laboratories around the world, on 2 January. Chinese officials formally reported on the viral pneumonia of unknown cause on 3 January. WHO alerted the global community through Twitter on 4 January and provided detailed information to all countries through the international event communication system on 5 January. Where there were delays, one important reason was that national governments seemed reluctant to provide information.

I know I am digressing into a defense of WHO, but that ties into the wider problem of too many governments and their voters believing that global governance is ineffective at best and harmfully dysfunctional at worst. We Americans, in particular, as constituents of the richest country in the world, have more sway than any society in how institutions like the U.N. function—or indeed whether they are even allowed to function.

As our progress with polio, smallpox, and many other diseases makes clear, what many Americans decry as “globalism” is actually more practical and effective than we think, and increasingly more relevant than ever. We fortunately have many potential outbreaks that never happened to prove it.

The Thankless Work of the WHO

Despite having one-fourth the budget of the American CDC—and a host of structural problems owed to being governed by nearly 200 countries—the WHO does quite a lot of good work, most of it behind the scenes and thus unappreciated—hence most Americans being indifferent, if not supportive, of our recent withdrawal.

➡️ It helped eradicate smallpox, a scourge of humanity throughout history that used to kill millions annually, even into the mid 20th century. This was accomplished partly by getting Cold War rivals the U.S. and Russia to consolidate their scientific and technological resources. In 1975, less than a decade after launching this effort, smallpox was vanquished.

➡️ It is close to eradicating polio, another horrific infectious disease that was once widespread, but now lingers in only two or three countries. Rates of polio infection dropped 99% since the global campaign was launched in 1988.

➡️ HIV/AIDS is no longer the death sentence it used to be, thanks in large part to the WHO, which reduced the cost of HIV medication by literally 95.5%. Over 80% of people with HIV/AIDS use drugs backed by the WHO; consequently, AIDS-related deaths have declined by over half since their peak in 2004.

➡️ The WHO is currently working on reducing the cost of insulin as well, as nearly half the world’s 80 million diabetics cannot afford it (including in the U.S.). It hopes to achieve the same results as with HIV/AIDS, through the same process known as “prequalification” (in which cheaper drugs, mostly from developing countries, are approved for safety and efficacy, allowing them to enter the global market).

➡️ In 2017 alone, it helped stem a yellow fever outbreak in Brazil (by providing 3.5 million vaccine doses), provided vaccines to nearly five million children in Yemen in the midst of its civil war; expanded mental health support to Syrians affected by their civil war; and provided new healthcare support (such as ambulances) in places like Iraq and South Sudan).

➡️ With respect to COVID-19, the WHO has shipped literally millions of items of personal protective equipment to 133 countries. It has launched a global trial involving the world’s top medical experts to find the most promising treatments and vaccine. As of now, 5,500 patients have been recruited in 21 countries, with over 100 countries joining or expressing interest in joining the trial.

➡️ Early on, the U.S. received vital early epidemiological data from China only because the WHO used its good relations to broker access. That’s the same reason the otherwise secretive Chinese eventually published the first genetic profile of the virus for the world to use. Against initial resistance, the WHO succeeded in making China allow observers into the country; in early February, an international team led by the agency visited Wuhan, including those from the CDC and NIH.

➡️In 2018, the WHO warned the world that it was not ready for a pandemic and needed to do more. It declared COVID-19 an emergency on January 30, when there were still relatively few reported cases outside China. World leaders still had the info and time to act, and some countries responded immediately; South Korea, New Zealand, and others implemented an effective blend of policies that made them one of the top success stories. The WHO cannot be blamed for our slow response.

➡️ Even Trump himself seemed to acknowledge the WHO’s work with gratitude. In late February, he tweeted “Coronavirus is very much under control in the USA. We are in contact with everyone and all relevant countries. CDC & World Health have been working hard and very smart…” In the weeks leading up to its withdrawal, the U.S. was still leaning on WHO experts for assistance, with even Secretary of State Pompeo trying to get the administration to soften its break up with the organization.

As always, I welcome any fact checking on these claims.

Expecting Too Much from the W.H.O.

The World Health Organization’s annual budget is roughly the size of a large hospital and one-fourth the budget for the C.D.C.

With these comparatively small funds, the W.H.O. must carry out its official mission of ensuring “the highest possible level of health” for “all peoples.” That includes eradicating diseases (such as smallpox and soon polio), facilitating research and cooperation (which recently gave us the first Ebola vaccine), promoting nutrition, setting universal healthcare and medical standards, and responding to emergencies like pandemics.

With this small budget, backed by its pleading for further funds, the W.H.O. has shipped more than two million items of personal protective equipment to 133 countries, and is preparing to ship another two million items in the coming weeks. Just a couple days ago, it delivered one million face masks, along with gloves, goggles, ventilators and other essential goods to Africa. More than a million diagnostic tests have been dispatched to 126 countries worldwide and more are being sourced as we speak.

As early as February, the organization brought together 400 of the world’s leading researchers (including from rivals the U.S. and China) to identify research priorities. It launched an international “Solidarity Trial” involving 90 countries, to help find effective treatment, and is currently running a “mega-trial” of the four most promising COVID-19 treatments and vaccines from around the world.

The W.H.O. has developed research protocols and guidelines that are being used in more than 40 countries. It got 130 scientists, donors, and manufacturers to commit to speeding up the development and delivery of a vaccine.

Through its innovative online “OpenWHO” platform, the W.H.O. pools together the world’s knowledge and best practices and delivers it to frontline personnel rapidly through an app. Users take part in social learning network, based on interactive, online courses and materials covering a variety of subjects. OpenWHO also provides a forum for the rapid sharing of expertise, in-depth discussion and feedback on key issues. So far, more than 1.2 million people have enrolled in 43 languages.

Again, all this for the cost of running a big hospital. While the U.S. does contribute one-fifth of the agency’s budget, this amounts to $893 million—a drop in the budget of our annual budget, which includes over $700 billion for the military alone. Talk about bang for our buck.

Moreover, we had pledged $656 million for specific programs, including polio eradication, health and nutrition services, vaccine-preventable diseases, tuberculosis, HIV—and preventing and controlling outbreak. And we’re still trying to do more damage to them.

Even as it launches another international mega-trial of the most promising treatments and vaccines, the U.S. is stubbornly refusing to take part.

Lawfare does a great job of breaking down how absurd our expectations of the W.H.O. are. While it concedes that the W.H.O. dropped the ball with China (something I also admit), it also reminds us of the far bigger and more complex picture regarding its relations with member countries (and the inherently political nature of health problems to begin with).

The work of the WHO is inherently technical; it does not need to make the sort of charged political decisions demanded of the U.N. Security Council, where the vital interests of different countries repeatedly conflict. Nor is it required to take a stance on the sensitive ideological values of different countries, as human rights organizations must. And because the WHO’s mission is narrowly defined in relatively objective terms, its performance can be evaluated with relative ease—for example, by using straightforward public health metrics. This ought to give WHO officials incentives to act appropriately and reduce the risk that countries are unable to discipline it if it fails to. The WHO’s leadership in the eradication of smallpox and in advances against polio seemed to validate this theory.

[…]

It is tempting to blame the WHO itself for its problems—its notoriously complex bureaucracy, its decentralized structure, its “culture” or the persons who run it. But all of those things are a result of the political constraints it operates under, as many reform-minded critics have observed. Big bureaucracies are established to guard against errors. In this context, this means staying away from actions that will offend member states whose support (financial or otherwise) is necessary for WHO’s operations. The sorts of bureaucratic reform that WHO insiders and sympathetic critics have called for over many decades would not protect the WHO from leaders like Trump.

It turns out that even the expert-led technical interventions of the WHO are politically charged. And this is not just because some countries want to hide disease outbreaks from the world. Countries also disagree about the problems that the WHO should focus on in the first place. The setting of priorities and allocation of resources among different public-health challenges are policy choices, not technical choices. The WHO is not an anti-pandemic organization or an infectious-disease organization: It is a health organization, and health policy is intensely contested around the world.

Many of the familiar cleavages in international politics had begun to pull apart the WHO long before the coronavirus pandemic. People disagreed about which health threats should be given priority, and the WHO found itself torn between governments, interest groups, activists and donors who wanted the organization to give priority to different things—HIV/AIDS and other infectious diseases, tobacco use, obesity, even climate change. And then there is intense disagreement about whether the WHO should give priority to developing countries and, if so, how much. The WHO has set itself the goal of correcting global health care inequality, which begins to seem like a redistributive program from north to south—the sort of thing applauded by academics and commentators but politically explosive, to say the least.

As I have previously argued, the W.H.O. doesn’t have the resources or power to stand up to any country, especially since virtually every country plays a role in its funding, governance, and the election of its director-general. If even most of the world is deferential to China—only fourteen nations officially recognize Taiwan instead—how can we expect an organization responsible for so much, with a small budget, few personnel, and no sovereign power, to somehow be any different.

The Politics and Pragmatism of Progress

We might find the W.H.O.’s politics unseemly. At times they are certainly troubling, especially regarding Taiwan. (Though in fairness, most of the world, including the powerful U.S., has also officially shunted Taiwan in deference to China.)

But they are an inevitable, if not necessary, evil for an organization run by 194 countries full of rivalries, self-interests, and division. Its weaknesses very much reflect our own. International cooperation is not about singing kumbaya and getting along harmoniously; it is the sober and practical realization that, however divided the world is, there are problems bigger than any one country can handle (look at how the richest country in the world has struggled to contain this pandemic). That means making difficult, imperfect, and sometimes even maddening compromises.

It took working with a murderous bastard like Stalin to beat the Nazis in WWII, with the Soviets accounting for 80-90% of Axis losses at the cost of tens of millions of lives. (We also had to work with the bastard Nationalists and Maoists in China to accomplish the same feat against Japan, with the Chinese tying up most Japanese forces at similarly horrific costs.)

In the context of public health, this is nothing new. Even at the height of the Cold War, countries including the U.S. and the Soviet Union managed to set aside their differences and work through the W.H.O. to eradicate smallpox, a scourge of humanity that had killed hundreds of millions just in the 20th century.

With over 50 million cases and 2 million deaths annually, in 1958 Soviet virologist Viktor Zhdanov became the first to call on the W.H.O. to lead a global eradication effort. In 1966 Canadian-American epidemiologist Donald Henderson formed the U.S.-led Smallpox Eradication Unit to assist in this endeavor. A year later, the W.H.O. intensified global smallpox eradication with millions of dollars from around the world and a method developed by Czech epidemiologist Karel Raska. The Americans and Soviets provided most of the initial vaccine donations (no doubt, at least in part, to one up each other).

By 1980, the W.H.O. declared smallpox eradicated—the first human disease wiped off the face of the Earth, thanks to global cooperation.

Image may contain: people playing sports, possible text that says 'WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION MAY 1980 smallpox is dead!'

America’s Baffling Opposition to the WHO’s Breastfeeding Resolution

It seems that any institution that is global or multilateral in nature or name elicits visceral opposition by huge swathes of the American public. While there has long been an undercurrent of insularity and outright hostility in America towards the rest of the world, it goes without saying that under the present administration — which came to power on a platform of nationalism, protectionism, and revanchism against foreigners — the sentiment has been worsened to the point of absurdity.

The most salient recent example is our strange response to a sensible resolution at the World Health Organization (WHO) that no one would have imagined was controversial. Continue reading