J. Stephen Morrison and Anna Carroll. "WHO and President Trump on the Ledge." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, April 28, 2020. Accessed June 12, 2020. https://healthsecurity.csis.org/articles/who-and-president-trump-on-the-ledge/
Throwing Down the Gauntlet
On April 14, President Trump abruptly announced that the United States would suspend its funding for the World Health Organization (WHO) for 60 to 90 days to conduct a review of the global public health authority’s handling of the Covid-19 response. The White House provided little detail on the review’s scope and process. In his announcement, President Trump accused WHO of “severely mismanaging and covering up the spread of the coronavirus” and” of being a de facto accomplice to a Chinese campaign of misinformation.
The effects of the announcement are profound: at stake are U.S. support to WHO (over $400 million in 2019, exceeding 15 percent of WHO’s total budget); the integrity and capacity of WHO to respond to a historic pandemic; U.S. global leadership; and U.S. national security interests.
The White House alleges that WHO failed to act on evidence of human-to-human transmission provided by Taiwan in early January. This charge was particularly irksome to American defenders of Taiwan, which lost its WHO observer status in 2016. The actual story of what occurred in early January, as WHO struggled to understand this entirely novel virus, remains unproven. Further investigation will be needed to get to the facts.
President Trump claims that WHO “fought” his January 31 decision to ban travel from China, a step the president regularly hails as proof of early and aggressive action to combat the spread of Covid-19. In early 2020, WHO did voice opposition to restrictions on travel and trade to China, a policy position in line with International Health Regulations (IHR). In fact, WHO reiterated its position in response to travel bans imposed by several dozen states before the United States took this action. At no time did WHO single out the United States or any other specific country for implementing travel bans.
According to the White House, WHO delayed publicizing the severity of the outbreak under Chinese pressure. The administration points to the WHO Emergency Committee’s first convening on January 22—when the committee declined to declare a Public Health Emergency of International Concern (PHEIC)—as proof. Shortly thereafter, on January 30, the committee met for a second time and declared the novel coronavirus outbreak a PHEIC. Six weeks later, on March 11, WHO declared the outbreak a pandemic. Beginning in mid-January and throughout this period, WHO repeatedly urged countries to take the novel coronavirus seriously and strengthen disease detection capacities, often during its frequent, detailed press briefings with WHO senior staff.
President Trump’s decision to freeze funding has stirred loud calls within congressional Republican circles and pro-Trump media for investigations into the organization and the replacement of WHO Director-General Dr. Tedros Adhanom Ghebreyesus (known as Dr. Tedros). The State Department has subsequently removed references to WHO from fact sheets on the pandemic and accelerated the exploration of options to divert U.S. funds for Covid-19 and other public health initiatives to other non-governmental groups. Secretary of State Mike Pompeo has announced the administration is considering the possibility of creating an alternative agency to WHO. Diplomatically, the United States has opposed positive reference to WHO in a draft UN Security Council resolution calling for a global ceasefire to facilitate action against the pandemic.
WHO Stuck in the Middle
Much to its utter dismay, WHO finds itself thrust into the middle of a toxic geostrategic confrontation between the United States and China.
By pointing the finger at China—the administration’s preferred foil—and billing WHO as China’s agent, President Trump seeks to strike a sudden blow at multilateralism that will appeal directly to his electoral base. That step also satisfies the growing chorus of China hawks in the administration and in Congress who deeply resent China’s Covid-19 narrative: that China—in contrast to the United States and Europe—took early and aggressive action against the coronavirus and achieved quick success which now permits the reopening of its economy. These critics press for greater accountability and transparency from China, including an investigation of the possible accidental release of the virus from the Wuhan Institute of Virology. (It is important to note that there is no scientific evidence to support this theory.) For some time, these China hawks have been upset over Taiwan’s exclusion from the annual World Health Assembly (a decision taken by a vote of WHO member states, not the WHO Secretariat.)
President Trump’s actions open an urgent debate over WHO’s role and performance in the global response to Covid-19 and its relationship with the Chinese government. This unfolds against the haunting backdrop of an American society reeling from dual crises. As the rush toward the U.S. presidential and congressional elections in November accelerates, Americans face a devastating epidemic (nearly one million cases and over 55,000 deaths) and a national economy careening toward a deep recession or worse, with over 27 million having filed for unemployment.
Any debate over WHO reform must be grounded in the reality of what WHO is and what it is not.
WHO is first and foremost a technical agency, its work overseen and implemented by the WHO Secretariat, under the direction of the Director-General, Dr. Tedros. The Director General is an appointed administrator who shares authority and resources with six elected regional directors.
WHO serves core technical functions. It sets global public health norms and provides scientific guidance; it rallies the world’s public health and biomedical communities to resolve scientific unknowns for new pathogens such as the coronavirus, accelerating the development of diagnostics, therapeutics, and vaccines; and it leads and coordinates the international response to dangerous outbreaks. Especially important for low- and lower-middle-income countries, WHO is the lead source of technical expertise and programmatic support on infectious diseases, maternal and child health, noncommunicable diseases, and nutrition.
By its 1948 constitution, WHO is a member-states organization. The WHO Secretariat’s appointed leadership, by definition, serves its 194 member states with considerable deference, whether China, the United States, or others. The WHO Secretariat has limited leverage over its members, with no power to conduct inspections, name or shame states, or otherwise enforce state compliance with IHR. It does not possess its own intelligence capacities and is overwhelmingly dependent on member states for data, access, and funding of WHO’s voluntary programs, which account for approximately 80 percent of its budget. Under current arrangements, when an outbreak does occur, the WHO Secretariat has few options but to accept on face value the data provided by the member state experiencing the outbreak.
Errors are inevitable in health emergencies, especially in the opening phase of urgency, confusion, and high uncertainty over what the pathogen is and what true dangers it poses. It should come as no surprise that WHO made errors in the early stages of the Covid-19 outbreak. Subsequent after-action analysis, standard fare for health emergencies, will elucidate them.
It is also critically important to differentiate between WHO and China. In the early months of the Covid-19 outbreak it was China—not WHO—which made the consequential decisions that kept the rest of the world in the dark and hastened the spread of the novel coronavirus.
It was China, not WHO, that engaged in a systemic cover-up of the initial outbreak in Wuhan in late 2019, before disclosing the outbreak to WHO on December 31. Even after it began to address the outbreak in earnest, it was China, not WHO, that was slow to share epidemiologic and specimen data with the outside world (although it did publish the virus’s genome on January 12). There is a widespread consensus today that China’s official case counts and fatalities seriously understate the extent of the outbreak: responsibility for that lies at China’s door, not WHO’s. Further, China denied international scientists access to China until mid-February, when it finally agreed, following repeated WHO overtures, to the entry of a WHO delegation that included two prominent American experts.
The United States Boxed In
President Trump has identified legitimate areas of concern regarding WHO’s performance, including the speed of the Emergency Committee decisions and WHO’s inability to challenge and overcome China’s obfuscation. Taiwan’s status, a matter decided by member states, not the WHO Secretariat, remains problematic.
The Trump administration now finds itself alone, isolated in the world. Its conflation of WHO’s actions with China’s decisions, its baseless allegations, and its extreme threat to undermine WHO amid a historic pandemic have won no external allies. Instead, these actions have earned the administration enmity and scorn from all directions and rallied most major nations to publicly support Dr. Tedros.
Efforts to enlist open criticism of WHO from Japan, Australia, Poland, and Hungary fell flat. Bill Gates described the freeze in funding as “as dangerous as it sounds.” Lancet Editor-in-chief Richard Horton labeled it “a crime against humanity.” Former President Jimmy Carter released a statement that he is “distressed by the decision to withhold critically needed US funding for the World Health Organization, especially during an international pandemic.”
On April 19, President Trump hosted a video conference with the leaders of the Group of Seven industrialized nations (G-7). The call focused heavily on WHO, as the president continued to accuse it of mismanagement of the Covid-19 response. Immediately afterwards, France, Germany, Canada, Japan, and the European Union all issued strong statements calling for continued support of WHO.
Domestically, reactions have largely fallen—but not entirely—along political lines. Congressman Jim Jordan (R-OH-4), the ranking member of the House Committee on Oversight and Reform, along with 13 other Republicans issued a letter to Dr. Tedros on April 9 demanding documents and communications regarding WHO’s Covid-19 response and its relationship with the Chinese government. Shortly thereafter, House Democrats issued a letter calling for the reinstatement of U.S. support of WHO. Several Senate Republicans have echoed the president’s claim since his announcement, calling for the Director General’s resignation. Senior administration officials—most notably Dr. Tony Fauci and Dr. Robert Redfield—have registered their praise of WHO and its extensive partnerships with the United States. Senator Roy Blunt (R-MO), the powerful Republican head of the Senate Appropriations Subcommittee responsible for health, has openly voiced his preference that any review of WHO take place after the crisis has passed. Prior to President Trump’s April 14 announcement, Secretary of State Pompeo publicly stated the same preference.
What Can Be Done?
The U.S. funding freeze, if made permanent, will have severe public health and national security implications. It will damage U.S. standing and U.S. national interests. Any effort to create an alternative agency will likely attract little support.
Cutting U.S. funds will immediately jeopardize the global response to Covid-19, particularly in the poorest and most vulnerable parts of the world, which rely overwhelmingly upon WHO leadership, funding, and technical support. The pandemic is poised to strike these countries’ populations and economies with a ferocity that could well exceed what has been witnessed thus far in the United States and Europe. If the United States carries forward with its threat to cripple WHO at this historic moment, it will potentially contribute to destabilizing these countries—and by extension—weaken U.S. national security.
A prolonged funding freeze will compromise many other longstanding global health programs. U.S. contributions to WHO fund 18 percent of its polio eradication activities, 18 percent of its health emergencies preparedness and response (including the effort to stamp out Ebola in the Democratic Republic of Congo), 21 percent of its vaccine preventable diseases programs, and 11 percent of its nutrition services. These programs enjoy deep bipartisan Congressional support and the goodwill and support of the American people.
Yemen is the first dramatic case study of how dangerous and damaging a halt of U.S. support to WHO—amid the coronavirus pandemic—can be in practice.
Yemen is the world’s worst human and health catastrophe. Nearly half of its medical facilities are inoperable, and 85 percent of the population is dependent on emergency assistance for survival. The first Covid-19 case has been confirmed, and the race is on to avert a runaway outbreak. WHO remains the central, most vital international institution responding to Yemen’s deep and enduring health and humanitarian crises, now including the advent of Covid-19. WHO is actively equipping 32 hospitals with Covid-19 isolation units and organizing the purchase and delivery of protective gear, test kits, reagents, and ventilators. It is funding and organizing over 300 five-person Yemeni investigative teams to support Covid-19 detection and reactivating 26 Emergency Operation Centers (created two years ago to battle the cholera outbreak).
Since Yemen’s devastating internal war began in 2015, the United States has been the most generous and consistent source of health and humanitarian assistance, much of it delivered through WHO. For the United States to cease supporting WHO in Yemen at this moment in time seems unthinkable.
The immediate question that this storm begs: is there still time for practical steps that might quietly walk back the United States and WHO from the ledge, provide face-saving measures for all involved, and preserve WHO’s functionality at this moment of crisis while also holding out the credible promise of future steps to reform and strengthen WHO?
The answer: perhaps, if we are very lucky.
Reportedly, early dialogue between the U.S. ambassador to the United Nations in Geneva and WHO did not yield fruit. Yet there is still the possibility for dialogue between the Trump administration and WHO leadership to agree upon steps that could ultimately strengthen WHO and the international response and allow for a restoration of U.S. global leadership, including support to WHO. Under such a scenario, key members of Congress, both Republicans and Democrats, who have some say over any reprogramming of U.S. funds obligated for WHO, can play a pivotal role in quietly brokering a resolution. G-7 member states can also actively press for common sense compromises.
The playbook is straightforward, provided there is political will and good faith. The first step is to lower the noise and temperature and commit to serious diplomacy, with the goal of improving the performance, capacity, accountability, and transparency of WHO. The second is to separate consideration of the WHO Secretariat from the Chinese government. Both need to be held accountable, but there can be no progress when the two are conflated.
The third is to lay the groundwork for an interim review of the performance of both the WHO Secretariat and WHO member states (including China and the United States), which might be authorized by the virtual World Health Assembly in May 2020 and completed by the Executive Board session in January 2021. The interim review of WHO’s response to the West Africa Ebola crisis, conducted between January and May of 2015, provides a valuable precedent.
An interim review of WHO’s response to Covid-19 would need to:
- Investigate the critical events of early January 2020, which remain a source of great dispute;
- Consider how to accelerate the decisionmaking process of the WHO Emergency Committee, including possibly establishing interim levels or categories of emergency;
- Examine the formal policy set by WHO member states regarding the treatment of Taiwan. The Chinese government is currently blocking Taiwan from WHO membership status, although Taiwan participates extensively in the WHO Secretariat’s technical work;
- Propose revisions to the IHR, most importantly their current lack of enforcement mechanisms, which result in WHO lacking any inspection powers. This is in contrast to the International Atomic Energy Agency (IAEA), for example, which can conduct inspections of member states’ nuclear energy programs without providing advance notice.
The review might also return to a fundamental question that surfaced during the West Africa Ebola crisis: whether the time has come for the WHO Emergency Program to become independent, like the World Food Programme and UNICEF. An independent Emergency Program with its own budget and governing structure might be able to operate with greater authority and speed. But such an institution would also need to be integrated with all of WHO’s health programs, ensuring the close alignment of both public health preparedness and response efforts.
Such a review will inevitably raise the question of whether member states are truly prepared to yield some measure of their sovereign power to grant WHO new authorities to achieve greater transparency and accountability by member states during an infectious disease outbreak. Ultimately, member states—including the United States—will decide whether this shift in power can occur.
The threat posed by the Trump administration to WHO is serious, real, and urgent. Little time remains to avoid bad outcomes with major consequences. A turn to common sense solutions can create the opportunity for the United States to reclaim global leadership and advance the common good of humanity amid this dangerous global crisis that threatens us all.
J. Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. Anna Carroll is an associate fellow with the Global Health Policy Center.
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