• The virtues and vices of the WHO

    The World Health Organization’s dismal handling of the Ebola outbreak has led to calls for sweeping reforms to the world’s system for managing infectious disease. The consensus view, though, is that we shouldn’t start from scratch. Laurie Garrett captures the prevailing wisdom in her incredible Foreign Affairs article on Ebola:

    The WHO performed so poorly during the crisis that there is a question of whether the world actually needs it. The answer is yes, it does—but in a revised form, with a clearer mandate, better funding, more competent staff, and less politicization. … If the WHO is going to remain the world’s central authority on global health issues—which it should, because there needs to be one, and it has the most legitimate claim to perform such a role—it needs to concentrate on its core competencies and be freed from the vast array of unrealistic, unprioritized, and highly politicized mandates that its member states have imposed.

    Garrett’s argument is squeezed between em-dashes: we’ve got to have a global health agency “because there needs to be one” and it ought to be the WHO because “it has the most legitimate claim to perform such a role.”

    There’s a lot to this. But it’s also really unsatisfying. Indispensable or not, why do we think the WHO will be any good at preparing for pandemics?

    In one respect, the WHO gets high marks. As is the case for most international organizations, the WHO’s membership is open to all states on an equal basis. With 194 members, that’s the organization’s signal virtue: it’s the only entity that can legitimately claim to represent the global community on matters of health.

    But that virtue is also a vice. Pandemic preparedness requires money, power, and political will. The WHO’s constitutional structure inhibits all three.

    Money. Equal participation means one state, one vote. The island nation of Niue (population 1,190) thus gets the same vote as China (population 1.357 billion). By my rough reckoning, states that collectively represent less than 4% of the world’s population can chart the WHO’s course. Rich countries won’t adequately fund an organization over which they exercise so little control.

    And they don’t. The WHO has global ambitions but meager resources; the Centers for Disease Control here in the United States has a budget that’s 50% larger. Because of resource constraints, only 34 employees were tasked with responding to emergencies when Ebola broke out.

    What’s more, only one quarter of the WHO’s too-meager budget comes from unrestricted state contributions. The rest comes from wealthy states and foundations—and those funds are typically earmarked for particular uses. The outside funding thus augments WHO resources while constraining its discretion. In particular, the WHO’s dependence on voluntary contributions hampers long-term planning and impedes sensible priority-setting.

    Power. In theory, an international organization dedicated to pandemic preparedness would help solve a fierce collective-action problem. We’re all better off if states are up-front about the spread of infectious disease within their borders. But states that come clean risk economic devastation, often because other states panic and impose counterproductive restrictions on travel and trade. A global institution could ameliorate that problem by preventing states from overreacting to the news of an outbreak. States will be more forthcoming if they if know they won’t be needlessly isolated.

    The trouble is that the WHO, per its constitution, has almost no actual power. It can cajole but not command. The WHO implored states not to prohibit travel to or from Ebola-afflicted countries, for example. When loads of states didn’t listen, the WHO couldn’t do a thing about it.

    I’m not optimistic that the WHO will be granted authority commensurate to its task. Every state worries—with some reason—that a powerful global institution might be insensitive to its interests. The WHO’s voting rules compound the problem. Countries like China, India, or the United States will be reluctant to give the WHO real power when representation is so skewed toward small states. And small states will naturally object to any effort to water down their power.

    Political will. Because the WHO lacks legal power, its success depends on establishing a cooperative, working relationship with its member states. If you don’t have a big stick, all you can do is speak softly.

    At the same time, the WHO knows that decisive action will inflict a lot of pain on particular countries. Travel advisories can prevent spread but decimate economies. Declaring an emergency can stem an incipient disease but stoke panic. States may need to be shamed into sharing data or samples.

    Taking decisive action thus risks sundering the very relationships that the WHO works so hard to cultivate. The WHO’s Director-General, Margaret Chan, has been roundly criticized for her lack of “independent and courageous decision-making” during the Ebola outbreak. But you might be cautious too if you feared that overreacting would make it impossible to elicit voluntary state commitments of resources or support.

    * * *

    None of this is to say we should scrap the WHO. Its limitations notwithstanding, it’s done some incredible work. (If you doubt it, go read up on SARS or smallpox.) But we should be candid about the WHO’s shortcomings and realistic about what we ask of it. On its own, the WHO won’t ever be great at pandemic preparedness. At best, the agency will be a key player in a broader ecosystem of international institutions, non-governmental organizations, and states that share its commitment to stemming the spread of disease.

    In the coming years, the biggest challenge for pandemic preparedness may not be fixing the WHO. It may be figuring out how to coordinate its work with entities that have different structures and distinct virtues.


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