Business and politics have always influenced international efforts to solve public health problems. Unfortunately that remains as true in the era of Ebola, Zika, and bioweapons as it did in the 19th century, when cholera—a disease that spreads more quickly and kills faster than any other pathogen—began its deadly global march. Beginning in 1817, cholera spread relentlessly from the Ganges Delta across Asia, reaching Europe in 1830 and North America in 1832, taking millions of lives along the way. It ultimately precipitated the first of 14 International Sanitary Conferences in 1851. At the time, the typical response to cholera was to quarantine ships traveling from affected areas, but this practice, which slowed commerce, was expensive and unpopular. The World Health Organization (WHO), whose origins lie in those early cholera pandemics, says they “were catalysts for intensive infectious disease diplomacy and multilateral cooperation in public health.” But in fact, the first six International Sanitary Conferences were entirely unproductive due to conflicting interests: government fears about losing profits from trans-Atlantic trade took priority over the need to reduce the international death toll. Consensus was achieved only at the seventh conference in 1892, after the opening of the Suez Canal for use by all countries made standardized quarantine regulations necessary. The participating states then unanimously approved and ratified the first of four International Sanitary Conventions, the forerunner of today’s International Health Regulations, which commit all governments to work toward stopping the spread of infectious disease and other global health threats.
In 1902 the first global health body, which after several name changes would become today’s Pan-American Health Organization, opened in Washington. The International Office of Public Hygiene followed in Paris in 1907 with the aim of overseeing and coordinating international quarantine and sanitation efforts against cholera and plague. The Health Organization of the League of Nations opened in Geneva in 1921, and in 1948, with the establishment of the United Nations after World War II, the organization became the WHO, with responsibility for disease surveillance enshrined in its constitution.The origins of the WHO, the UN agency tasked with responding to today’s global health threats, can thus be traced back to cholera, the most important global health threat of the 19th century.
The pandemic problem. In the 20th century, the WHO played a key role in success stories like controlling leprosy, eradicating smallpox, and eliminating polio from 95 percent of the globe. In recent years, its leadership in battling neglected tropical diseases and addressing the threat of antibiotic resistance has been exemplary. Its performance regarding 21st-century pandemics, though, has not engendered confidence. It failed to respond in a timely fashion to the recent Ebola crisis, which began with an outbreak in southeastern Guinea in early December 2013. Due to poor surveillance, the illness wasn’t identified as Ebola until March 2014. By April 1 it had killed 83 people in Guinea and spread to Liberia, and Doctors Without Borders was already warning of an “unprecedented epidemic.” But the WHO, unduly attentive to Guinea’s concern with avoiding the stigma of an outbreak, insisted the phenomenon was “limited geographically” and described it as ”an outbreak with sporadic cases.” It was not until August 8 2014, by which time nearly 1,000 people had died and the epidemic was out of control, that the WHO declared Ebola an international public health emergency.
Despite being widely criticized for this deadly delay, the WHO was still slow to respond to the Zika virus, the most recent global health threat. Spread by the hardy Aedes aegypti mosquito, and less commonly through sex, Zika is less deadly but in a way more terrifying than Ebola, a blood-borne disease spread by human-to-human contact, and one which was rapidly controlled once the WHO and the US Centers for Disease Control and Prevention (CDC) got their global act together. Ebola can end life, but Zika’s worst outcome happens at the very beginning of life, in utero; it has caused a pan-epidemic of microcephaly—abnormally small heads with associated neurological stunting—in the newborns of infected mothers. Not since Rubella, a vaccine-preventable disease responsible for stillbirth, brain damage, and blindness, have we seen a contagious disease capable of such congenital devastation. Brazil declared Zika a public health emergency in November 2015, and the CDC issued Zika travel warnings in mid-January 2016. But it took the WHO until January 28 to convene an emergency committee on the issue, and until February 1 to declare an international public health emergency.
In short, while the WHO should serve as a global front-line defense against pandemics and bioterror attacks, at the moment it does not look like it’s up to the job. The only possible solution is radical reform, and this much is widely acknowledged. The Ebola crisis sparked a number of post-mortems on the organization’s performance, including those conducted by the WHO’s own Advisory Group on Ebola, the UN Secretary-General’s High Level Panel on Global Health Crises, a joint report by the London School of Hygiene and Tropical Medicine and Harvard University, another joint report by the Independent Commission on Multilateralism and the International Peace Institute, and reports from the Overseas Development Institute and the US Institute of Medicine. There is no shortage of recommendations for reform, some of which have already been heeded. For example, in May, WHO member states agreed to establish the new Health Emergencies Programme to deal with disease outbreaks and humanitarian emergencies.
Fundamentally, though, most of these reports do not address the systemic problems that must be fixed if the WHO is to be ready for 21st century health threats. Some of these problems—like competing national interests and the power of private business—are not so different from those that stymied international health cooperation back in the 19th century. Unless the organization can increase its financial resources, eliminate the undue influence of donors and member states, and redress its subservient relationship with governments who are themselves responsible for health crises, it won’t be ready for our next pandemic.
Money and politics. Not surprisingly, the WHO’s decline in performance is linked in part to a declining budget. The governing body of the WHO, the World Health Assembly, is made up of health ministers from member states, and it dictates the size of contributions from each country. These contributions have not increased for several decades, with the result that member contributions make up less than 25 percent of the WHO’s $4 billion annual budget. Director-General Margaret Chan has the considerable task of raising the rest from philanthropists, wealthy member states, and private companies, even as her organization strives to fulfill its mission grappling with Middle East Respiratory Virus (MERS), cholera, Zika, Ebola, neglected tropical diseases, antibiotic resistance, the rise of superbugs, and myriad other issues. To be sure, common sense is not dependent on cash, and declaring Ebola an international emergency earlier could have mobilized financial resources for the WHO’s response sooner. Yet the cash problem is compounded by political obstacles to sound decision-making. The organization is structured so member states influence the choice of senior staff at the country level, and elect staff at the regional level. Regional directors must even campaign for office. This creates a situation in which the regional directors, wishing to please their patrons, may prioritize government preferences such as trade and tourism over public health needs. They may not wish to issue quarantines or sanctions that might hurt their home country’s perceived economic interests. Meanwhile, only one third of the WHO’s 194 member states have actually implemented the International Health Regulations.
Governments, moreover, have a long history of downplaying infectious disease. While the WHO has occasionally called out countries for doing so—for example, it rebuked China over “inadequate reporting” of SARS—the organization has acquiesced in other cover-ups. Although Syria experienced a cholera outbreak in 2009, this was unacknowledged by the WHO until November 2015. Nor did it acknowledge the re-emergence of polio in Syria in 2013—denied by the Syrian government for four months until laboratory confirmation was provided by independent doctors with the help of the Turkish government.
(Unfortunately, the WHO is not the only international organization that has failed to accurately report on health threats in states where the government is not reliably concerned with public health: The United Nations actively assisted the government of Zimbabwean President Robert Mugabe in covering up a cholera outbreak in 2008 and has refused to admit responsibility for a UN peacekeeper from Nepal having imported cholera into Haiti.)
The WHO’s political architecture and lack of financial clout also may help explain its stance—or lack thereof—on the summer Olympics, which will take place in Brazil in August. In May, as the World Health Assembly met to set the global health agenda for the coming year, a group of scientists sent an open letter to Director-General Chan, recommending that the Olympics be moved, delayed, or cancelled due to the global threat posed by Zika. The Olympics do represent an additional risk of spreading Zika beyond the 60 countries where transmission already occurs—teams from China, India, and the Gulf States, for example, will return home in the summer, peak season for Aedes aegypti, to places without the capacity for robust surveillance. But the WHO rejected this recommendation, which is less surprising after considering the lack of enthusiasm it inspired from the World Health Assembly, the WHO’s lack of financial clout, and the enormous sums of money that Brazil has invested in the Olympics and expects to reap from attendance and media coverage.
Undue influence. In an effort to formalize existing relationships with private corporations and protect against donors exerting too much sway, in May the World Health Assembly adopted its “Framework for Engagement with Non State Actors” after several years of negotiations. The need for a framework was driven in significant part by the need for financing. The WHO’s reliance on funding from the philanthropic and private sectors raises concerns of undue influence by a few big private donors. In reality, the new framework won’t safeguard the WHO from the pressure exerted by wealthy states to focus programming on diseases of the rich, such as obesity, rather than diseases of the poor, such as cholera. Even the best-intentioned philanthropists, like the Bill and Melinda Gates Foundation, may distort the WHO’s mission. The Gates Foundation is the WHO’s biggest private donor, funding 20 percent of the organization’s budget. The two entities’ interests are often aligned, for example on vaccine-preventable childhood illnesses and neglected tropical diseases. However, it was the Gates Foundation’s financial influence that set the WHO agenda to eradicate malaria—which may not be possible or even necessary—rather than control it, a feasible proposition that doesn’t set the WHO (or the Gates Foundation) up for failure.
Big pharmaceutical companies also exert influence on the WHO agenda. They donate tens of millions of dollars to the organization directly, but even more in kind, such as vaccines and drugs. Pfizer, for example, donates azithromycin, which cures trachoma, the leading cause of preventable blindness worldwide. The WHO then distributes the drug directly to health ministers, with the beneficial result that each year, several million people are able to see again. On the other hand, drug companies’ pricing choices made anti-retroviral agents unaffordable for years for millions of Africans living with HIV, while the companies’ financial leverage meant that the WHO—along with Western governments and the UN agencies UNAIDS and UNICEF—sat back without protest.
The WHO is not the only health organization that faces conflicts of interest due to funding issues. In 2009, the pharmaceutical company Roche funded the CDC’s “Take 3” flu campaign. The CDC in turn promoted Roche’s Tamiflu, a flu prevention and treatment drug, as the answer to the H1N1 strain prevalent that year. CDC director Tom Frieden went on record wrongly telling the public that Tamiflu could “save your life,” a debatable assertion given the lack of evidence and one that was questioned by the US Food and Drug Administration. At least the World Health Assembly’s rules say the WHO won’t accept funds from tobacco companies or arms manufacturers. In 1996, the National Rifle Association’s lobbying of the US Congress slashed $2.6 million from the CDC’s budget, restored only when the CDC was effectively barred from discussing gun violence, a massive public health problem in the United States. In 2012, President Obama ordered the CDC to start studying gun violence again, but it still avoids the issue for fear of retaliation. The lack of any CDC declaration about industry funding, coupled with the influence of politically powerful bodies like the National Rifle Association, undermines public trust in CDC recommendations.
Ignoring wars. For the WHO, the real elephant in the room when it comes to reform is the issue of global threats arising in conflict zones and fragile states. Not a single report from the WHO advisory group, the UN Secretary-General’s High Level Panel (which I briefed and submitted a plan to), or any independent organization has examined armed conflicts as major drivers of infectious threats and bioterrorism, even though there is a global abundance of conflicts, and evidence of their role is clear. Indeed, wars are among the best incubators of infectious disease. They undermine public health systems while displacing populations and forcing them to live in crowded and unsanitary conditions. Current conflicts in the Middle East and Africa have created the biggest population of refugees and displaced people since World War II—tens of millions of malnourished people highly vulnerable to new and old pathogens.
The problem is only compounded by the WHO’s operational closeness to governments—by its primary role, enshrined in its constitution, of supporting the ministries of health of member states. Even in peacetime, governments may subordinate public health to other priorities, as occurred during the 2012 cholera outbreak in Cuba, where state authorities forced doctors to certify cholera deaths as “acute respiratory insufficiency.” (Those who didn’t were arrested.) In Saudi Arabia the same year, the government interrogated the virologist who published his discovery of MERS online, forcing him to resign and relocate to Egypt. The problem is much worse in conflict settings when state authorities stop acting in the interest of significant portions of their populations, as in today’s Syria, Yemen, and South Sudan. In such circumstances, because the state has an interest in downplaying the destruction it is causing, the accuracy of the WHO’s reporting and its recommended responses are likely to be compromised. Indeed, even the WHO’s access to areas afflicted by enormous public-health problems can be compromised by a government’s interest in covering up the fact that it is targeting civilians.
Today, the worst of these health crises is in Syria, where the government uses disease and deprivation as an element of war strategy. The Syrian government has sought to undermine public health in opposition-held areas by making it a crime to provide medical care to injured militia members and civilians, targeting hospitals and other health facilities, and withholding public health essentials such as vaccinations, chemicals for water treatment, and sanitation. To cover up its actions, which are warcrimes, it denies and underreports health problems. Hospitals have literally had to go underground to survive aerial bombardment, and medics have had to find ingenious ways to overcome physical obstacles, such as by smuggling polio vaccines across government checkpoints in milk canisters. Rather than call out the Syrian government for these war crimes, the WHO has effectively endorsed a government-imposed system for distributing medical supplies and aid that severely discriminates against civilians in opposition-held areas.
Even worse, according to first-hand sources in Syria and documentary evidence from WHO headquarters in Geneva, since 2014 the WHO’s Syria office has been procuring materials and equipment for the Syrian National Blood Bank, which is controlled not by the Ministry of Health but by the Ministry of Defense. The WHO thus subsidizes the principal government department that systematically kills and incarcerates doctors, attacks hospitals, and destroys public health infrastructure across the northern Syrian governorates, which are inhabited by millions of civilians. It backs a public-health infrastructure that is likely to be providing services to people on the basis of political sympathies rather than need.
The inability or unwillingness of the WHO to act independently of a member state is dangerous—for the people of Syria and, because of the precedent it sets, for people caught in other war zones. This fact should have prompted specific recommendations for WHO reform. Instead, the report by the UN Secretary-General’s High Level Panel focuses “on cases where outbreaks of communicable disease are the root cause of a crisis.” That detached perspective endorses the fiction that epidemics happen in a vacuum, rather than in environments manipulated by human conduct. Any effective preparedness plan designed to address the full range of potential pathogens must deal with the complex reality of the world as it is, complete with civil wars and fragile states.
War zones beg for an additional WHO reform: Infectious disease surveillance in settings of conflict and insecurity is compromised by the WHO’s insistence on laboratory verification as per the International Health Regulations. That cautious approach makes sense in a well-functioning state where the most serious problem is the need to rule out false positives. But in conflict zones, the problem is the opposite. Laboratories have been destroyed, access to those that remain may be limited, and there is a shortage of professionals who can conduct lab testing. As a result, many cases of infectious disease are never counted. Even after the Syrian government was forced to reverse its 2013 claim that lab tests for poliovirus at its national laboratory in Damascus were negative—“finding” the virus only after laboratories in Turkey and the Netherlands did so in the same samples—and despite the absence of any other labs in the country and the difficulty in getting samples across international borders within the two-week diagnostic time period, the WHO refused to count children crippled by polio as polio victims unless a lab test had been conducted.
To rectify this gap, different standards are required for counting suspected cases of infectious disease in war zones, with laboratory testing supplemented by clinical diagnosis and rapid diagnostic tests in the field. Yet the WHO has resisted making this adjustment, and the reform process has not addressed it. Innovative surveillance systems such as PROMED, the internet-based reporting tool used by the Saudi Arabian doctor who posted the first case of MERS, can supplement traditional reporting, merge surveillance data, and ensure information sharing for the timely detection of serious global threats. To effectively track disease in war-torn areas, international health institutions should make it standard procedure to include non-traditional surveillance tools and reports from a broad range of public health actors, both in and out of government.
The WHO also needs to be realistic and recognize that the International Health Regulations are unenforceable. In 2014, Bruce Aylward, then the organization’s assistant director-general for polio and emergencies such as Ebola (and now the director for outbreaks and emergencies), confidently called for the Syrian government to declare a national polio emergency and vaccinate all Syrians who were leaving the country, just as they were required to do under the regulations. Relentless airstrikes by the Syrian air force, though, revealed a government more committed to creating refugees than protecting its citizens from polio or preventing a national public health threat from spreading more widely. (Polio spread into Iraq from Syria in 2014. Doctors associated with the Syrian political opposition based in Turkey eventually contained polio in Syria through a mass vaccination effort.)
There is plenty of legal basis for the WHO to do a better job of standing up to governments that do not prioritize public health. International humanitarian law codifies the right to treat the sick and wounded, to give aid, and to receive it. Chan raised this issue in her speech to the annual World Health Assembly meeting in May, but all of the meeting’s reform panels overlooked it. Nor did any of the reports on WHO reform address the global challenges to humanitarian action in war zones. Despite the important role played by front-line doctors (who detected polio in Syria) and Doctors Without Borders (who called out Ebola in West Africa), there have been no recommendations concerning the human right to receive healthcare and the imperative to protect those delivering it.
The future. Outbreaks of infectious diseases are inevitable. Viruses will continue to jump from animals to humans and spread through the population. We can, however, prevent outbreaks from turning into pandemics. The tools exist. They include rigorous disease surveillance, rapid response systems, and investment in public health in the most vulnerable parts of the world. Following World War II, the global spirit of cooperation and collective responsibility drove the eradication of smallpox and led the United States and the Soviet Union to share polio vaccines. But in recent decades, we have seen a bunkerized approach to global health that ignores the growing crises in conflict zones and chooses not to fund the WHO, leaving it open to political and financial influence.
All of the various reform panels have recommended that the WHO create some kind of emergency response unit, and it answered with the Health Emergencies Programme. The barriers to this project’s success, though, are enormous: Emergency response has never been in the WHO’s DNA the way disease surveillance has, a mere third of the program is funded, and many member countries prefer international bodies to remain subservient to state needs rather than develop global legitimacy and influence.
Transferring global health problems to other UN agencies is not the answer, because the United Nations is a club of governments, with the same tendency to prioritize government interests over human rights. So we may as well get on with the rehabilitation of the WHO, the agency we have and need. The international health system was founded on the recognition that individual governments cannot handle all public health problems on their own. A system that was designed to stand above governments, though, has now become unduly reliant on them.
The responsibility is collective. To make it work, we must prioritize global health over governmental assertions of sovereignty. Better detection isn’t enough. Neither is more funding, although it will help achieve a crucial political independence. Rebuilding public trust and moral authority requires that the WHO place the right to health first, creating an organizational culture that promotes integrity and transparency of decision-making over political ambition. Pandemics are the single biggest threat humanity faces. The question is, do we collectively care enough to exercise our option to prevent them?