Trump Faces Off With the WHO: Sorting Through the Allegations

President Donald Trump’s decision to halt payments to the World Health Organization (WHO) pending a review of its handling of the coronavirus pandemic followed weeks of verbal swipes at the institution. In declaring the funding suspension on April 14, Trump said the U.N. agency “failed in its basic duty and must be held accountable…The outbreak could have been contained at its source with very little death.” He had telegraphed the cutoff in criticism at an April 7 press conference, saying, “We’re going to put a very powerful hold on them.” While his critics saw the lashing out as part of his numerous attempts to deflect blame from his own failures in the response, the WHO’s actions and statements haven’t always helped its own cause either.

Established in 1948, the World Health Organization has played a vital role in combating global diseases. From 1959 to 1979, the organization helped organize efforts to eradicate smallpox. More recently, the WHO has coordinated responses to emerging diseases, including SARS in 2003, the H1N1 “swine flu” in 2009, and Ebola in 2014-2016, though its handling of the more recent of those epidemics has come under criticism, even in some cases from its own advisers. While the organization features most prominently during global outbreaks, much of its routine work focuses on achieving the U.N. Sustainable Development Goals, including actions to reduce maternal mortality, increase health screenings, and coordinate global health expertise.

The WHO is comprised of 194 member states, who meet annually through the World Health Assembly (WHA). In 2017, with the backing of Asian and African countries, including China, Dr. Tedros Adhanom Ghebreyesus, a former health minister and foreign minister for Ethiopia, won what The Guardian describes as a contentious election to become director-general. The United States and some other countries had backed another candidate. Now, Tedros leads an organization that, for the first time in its history, is confronting a halt in U.S. funding.

An overview of the WHO’s handling of the COVID-19 pandemic shows that, while it has made significant mistakes, the organization, like other U.N. agencies, is constrained by its role as a neutral coordinating body with limited enforcement power. Yet, the Trump administration — and in some instances, even the organization’s supporters — have criticized the WHO on its timing, deference to China, handling of Taiwan, and recommendations against travel bans.

The following lays out the Trump administration’s allegations and related actions by the WHO.

Timing of Response

The U.S. president’s criticism has focused in part on the organization’s pace in responding to the viral outbreak, and includes allegations that the WHO initially downplayed the threat. “The delays the WHO experienced in declaring a public health emergency cost valuable time,” Trump said on April 14. He added, “there was credible information to suspect human-to-human transmission in December 2019, which should have spurred the WHO to investigate and investigate immediately.” A week earlier, on April 7, he had said, “They could have called it months earlier. They would have known, and they should have known. And they probably did know.” On April 8, he said, “In many ways they were wrong. They also minimized the threat very strongly.”

The record thus far shows that the Chinese government informed the WHO on Dec. 31 of a pneumonia outbreak in Wuhan, although rumors of a new virus already had begun circulating on social media. A day later, the WHO activated its incident management system, six days before the U.S. Centers for Disease Control and Prevention (CDC) followed suit.

On Jan. 7, after receiving information from the Chinese government, the WHO identified the outbreak as a form of coronavirus. On Jan. 12, the WHO shared the full genome sequence, two days after Chinese scientists posted the sequence online. While experts have said this 12-day delay was a slow response, the WHO has limited alternative sources of information and relies primarily on its member countries, like China, to provide full and accurate information. China reportedly had sequenced the genome by the end of December, but waited to share that information with the world and the WHO.

By mid-January, the WHO also had issued a request to the Chinese government to send a team to Hubei Province, the center of the outbreak and where Wuhan is located, but China refused. David Fidler, who has served as an adviser to the WHO, also noted on Just Security that “the United States had the opportunity and the obligation to share information” with the WHO about what it knew, potentially from its intelligence agencies, about the spread of the virus in China. Furthermore, the Washington Post reported on April 19 that the CDC, in standard practice, had staff detailed full-time at the WHO in Geneva as the viral outbreak emerged in China, and that those officials were transmitting information back to the CDC in Atlanta at the time, also standard practice.

On Jan. 22, the WHO convened an Emergency Committee, a body of global health experts, under its International Health Regulations (IHR), a global agreement that includes the United States and that was last updated in 2005. The committee was to assess the outbreak and consider declaring a Public Health Emergency of International Concern (PHEIC), the organization’s term for an “extraordinary event” that “constitute[s] a public health risk to other States through the international spread of disease.” At a press conference in Geneva that same day,  Dr. Michael Ryan, WHO’s executive director of its Health Emergencies Program, warned of the potential consequences, saying the “primary issue is to limit human-to-human transmission.”

The committee met on Jan. 22 and 23, even as China announced a lockdown on Wuhan. But the panel was split on whether to declare a global public health emergency, and called for more epidemiological information. Nevertheless, on Jan. 23, the WHO warned that “human-to-human transmission is occurring,” that the new virus could “appear in any country,” and that countries should be ready for the possible need to impose “isolation” and other “prevention” methods.

But Trump didn’t seem worried. In an interview with CNBC at the World Economic Forum in Davos, Switzerland, the first question he was asked was whether he was concerned about the reports of coronavirus coming from China. “No, not at all,” Trump said. “We have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine,” he said.

The WHO Emergency Committee reconvened on Jan. 30 and determined that the conditions had been met for an international emergency declaration. That day, with 98 confirmed cases reported in 18 countries outside China, the WHO declared a PHEIC, urging countries to begin screenings, accelerate vaccine and testing development, and review their protocols for outbreak responses. The next day, following the announcement, Secretary of Health and Human Services Alex Azar declared a U.S. public health emergency (six weeks before Trump declared a national emergency), but stressed that “the risk of infection for Americans remains low,” and said, “The United States appreciates China’s efforts and coordination with public health officials.”

While Trump on April 14 called this eight-day delay between the Emergency Committee’s first meeting and its recommendation of the international emergency declaration a “tremendous amount of time,” he and other backers in his administration expressed little concern at the time. The same day the WHO declared the international emergency, Trump told a campaign rally, “We have it very well under control,” and Commerce Secretary Wilbur Ross told Fox Business, “I think it will help to accelerate the return of jobs to North America.” On Feb. 10, Trump again interviewed with Fox Business, saying China has “everything under control. We’re working with them. You know we just sent some of our best people over there, World Health Organization, a lot of them are composed of our people.”

Over the month of February, the WHO held near-daily press briefings, warning countries to stay vigilant but declining to recommend travel bans or declare a pandemic. “Does this virus have pandemic potential? Absolutely it has. Are we there yet from our assessment? Not yet,” Tedros said on Feb. 24. He urged countries to “focus on finding, testing, treating, and isolating individual cases.” Asked by CNN about the WHO’s comments a few hours later, Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, called the term pandemic “borderline semantics… Pandemics mean different things to different people.” On the same day, Trump praised the WHO, tweeting “CDC & World Health have been working hard and very smart.”

But pressure grew to declare a pandemic, as the coronavirus began to spread even more rapidly outside China in early March, including in Europe. The German health minister said on March 4 that he considered the outbreak a pandemic.

Nevertheless, on March 9, WHO’s Ryan justified the organization’s caution, saying, “Unlike flu, we can still push this back. We can still significantly slow down this virus. The issue is what the reaction to the word will be. Will the reaction to the word be, let’s fight…or will the reaction be, let’s give up?” Two days later, on March 11, with 118,000 cases and 4,291 deaths in 114 countries, the WHO officially declared the spread of COVID-19 a pandemic.

The decision to wait until mid-March stemmed in part from the lack of a clear definition of what constitutes a “pandemic.” The organization refrained from characterizing the 2003 SARS infections and the 2014-2016 Ebola outbreaks as pandemics. But it did use the term for the 2009 outbreak of H1N1, also known as “swine flu,” which may have infected over 20 percent of people worldwide, but was far less deadly — it killed 12,469 people in the United States, although models estimate that between 151,000 and 575,400 people may have died from it globally, according to the CDC. The WHO posted a definition of pandemic on its website in February 2010, but a 2011 paper in the WHO bulletin outlines the controversy over the pandemic declaration in the H1N1 case and the issues in classifying an outbreak a pandemic.

Unlike a PHEIC declaration, which typically would occur upon recommendation by an emergency committee such as the one the WHO convened on the coronavirus, the IHR makes no mention of criteria for a pandemic. A PHEIC legally requires member states to provide updates on the outbreak within their territory, while the IHR doesn’t address the concept of a “pandemic” at all. Although the WHO drew more criticism from public health experts and other commentators for waiting to declare a pandemic than the delay in its decision on a PHEIC, Trump made no mention of the pandemic declaration at either the April 7 or April 14 press conferences.

Allegations of Being a Mouthpiece for China

Trump also has attacked the WHO for what he sees as its friendliness toward China. “The WHO willingly took China’s assurances to face value… and defended the actions of the Chinese government, even praising China for its so-called ‘transparency.’” At the April 7 press conference, he said, “they seem to be very China-centric,” he said. “And they always seem to err on the side of China,” later stating, “If you look back over the years even, everything seems to be very biased towards China.”

Some of the most widespread criticism comes in response to a Jan. 14 tweet by the WHO that parroted false claims from the Chinese government, stating, “Preliminary investigations conducted by the Chinese authorities have found no clear evidence of human-to-human transmission.” This was later contradicted by reports from the Washington Post and The Guardian that the Chinese government had known of warnings from doctors in Wuhan about possible human transmission for weeks.

Other statements from the WHO from that same time indicated that there was some reason to believe human-to-human transmission was possible. On Jan. 10 and 11, WHO guidance issued to its regional health directors to be shared with local officials warned about “ease of transmission both by airborne droplets and contact with contaminated surfaces, suggesting isolation procedures,” according to The Guardian. At a press conference on Jan. 14, acting head of WHO’s emerging diseases unit, Maria Van Kerkhove told reporters, according to Reuters, “It is possible there is limited human-to-human transmission…but no sustained human-to-human transmission.” On Jan. 22, the WHO confirmed in a tweet “evidence of human-to-human transmission,” with the caveat that the organization had not yet seen evidence of third- or fourth-generation transmission.

As for Trump, he was going out of his way to praise China and its president, Xi Jinping. Trump was asked on Jan. 22 in the Davos interview whether he shared the concern of some experts about China’s transparency over the coronavirus reports. “Do you trust that we’re going to know everything we need to know from China?” asked CNBC’s Joe Kernan. “I do. I do,” Trump replied. “I have a great relationship with President Xi.” On Jan. 24, he reiterated his praise in a tweet: “China has been working very hard to contain the Coronavirus. The United States greatly appreciates their efforts and transparency. It will all work out well. In particular, on behalf of the American People, I want to thank President Xi!”

Four days later, Tedros met with Xi and his health and foreign ministers in Beijing, and appeared to applaud Xi for his personal involvement, speedy response and transparency. “They are completely committed to transparency both internally and externally,” Tedros said on Jan. 28.

But he also noted that they had had “a series of very candid discussions” (sometimes diplomatic jargon for tense) on issues including containment of the virus to Wuhan, collaboration, and data sharing. Despite the possible signal that Tedros delivered a tough message that China needed to be more open, when the WHO declared the international public health emergency on Jan. 30, the director-general again praised China. That occasion might have been intended to support the Chinese government’s drastic shutdown in Wuhan:  “The Chinese government is to be congratulated for the extraordinary measures it has taken to contain the outbreak, despite the severe social and economic impact those measures are having on the Chinese people,” Tedros said. He also emphasized China’s “transparency” and said it set a “new standard” for outbreak response.

Some critics have linked this praise to China’s support for Tedros’ 2017 candidacy for the director-general position. However, the praise may also be also due to the organization’s role as a global health coordinator, public health experts told Vox. During the 2003 SARS outbreak, China was accused of covering up its early cases. While the 2005 International Health Regulations included provisions to prevent future coverups by legally requiring countries to provide accurate and timely reports to the WHO, these rules lack enforcement mechanisms.

So public praise of China by the WHO may have been aimed in part at ensuring China cooperated with the organization and with other governments. Devi Sridhar, the chair in global public health at the University of Edinburgh, told Vox in February, “Right now, the greater good is to create positive incentives for countries to collaborate with WHO — to share data, to let missions into China. If that means publicly [Tedros] has to praise China, I understand it.”

It is also fair to conclude that the WHO’s praise of China’s transparency followed the lead of the United States’ president.

Handling of Taiwan

Related to the criticism that the WHO is China-centric is the complaint that the organization has treated Taiwan unfairly and shut it off from global health processes. Much of this is related to U.N. rules that constrain the WHO’s handling of Taiwan. Under the 1971 U.N. General Assembly Resolution 2758, the U.N. switched its recognition to Beijing as the official Chinese government and removed Taiwanese representation from the world body. The WHO, as part of the U.N. system, did the same a year later. While the United States, for its part, also switched its recognition to Beijing in 1979, it has continued close relations with Taiwan, at varying levels depending on the administration in the White House. Recent Republican administrations, including the Trump administration, have cultivated closer U.S. ties with Taiwan, including for arms sales to support the small island nation’s defense.

Taiwan has long waged a campaign for greater recognition at the U.N. and the WHO. In the wake of the 2003 SARS outbreak, when Taiwan felt excluded from WHO processes, the organization signed a secret memorandum of understanding (MOU) with China in 2005 clarifying when the WHO could work with Taiwan. According to cables later leaked by Wikileaks, the United States supported the MOU. An article published by Brookings states the MOU specified “that any interaction between Taiwan and the WHO, other than in a case of acute emergency, [is] subject not only to approval by the WHO Secretariat but also by the Chinese Ministry of Health in Beijing.”

Some of the criticism of WHO related to Taiwan has focused on a Dec. 31 email from Taiwan to the WHO, warning of a pneumonia-like outbreak in Wuhan. Under the rules of the MOU, the WHO likely could not respond directly to the Taiwanese without PRC approval, which critics have pointed to as a missed opportunity to detect evidence of human-to-human transmission. The WHO, for its part, argues that the email makes no mention of human-to-human transmission, only the need for isolation. Taiwan says the possibility of transmission should have been inferred from the need for isolation.

On April 17, Trump wrote in two tweets, “Why did the W.H.O. Ignore an email from Taiwanese health officials in late December alerting them to the possibility that CoronaVirus could be transmitted between humans? Why did the W.H.O. make several claims about the CoronaVirus that [w]ere either inaccurate or misleading in January and February, as the Virus spread globally? Why did the W.H.O. wait as long as it did to take decisive action?” He appeared to cite comments by Lanhee Chen, a fellow at Stanford University’s Hoover Institution on Fox News.

Despite Taiwan’s relative success in fighting the coronavirus — the country has reported just 6 deaths and 426 cases as of April 22 —Taiwanese leaders also maintain the WHO has failed to adequately share information with them. Taiwanese officials say they have been left out of emergency meetings of the WHO and denied observer status at the World Health Assembly (WHA). The WHO, however, said at a Feb. 8 press conference it has cooperated with Taiwan in its COVID-19 response. It has a regional expert stationed in Taipei and invited two Taiwanese officials to a February forum on the disease.

Tensions between Taiwan and the WHO escalated in April. In an April 9 press conference, Tedros said he had been the victim of racist attacks and threats and identified Taiwan as the source. “I will be straight today. [The attacks came] from Taiwan,” he told reporters. The Taiwanese Foreign Ministry called the remarks “groundless” and “imaginary.”

At an April 15 press conference, the WHO defended its handling of Taiwan under U.N. rules, citing the decisions in the early 1970s on Taiwan’s membership in the U.N. and the health organization. WHO Principal Legal Officer Steve Solomon said Taiwan has a point of contact at the WHO and access to emergency information, and that the WHO has been sharing information with Taiwanese scientists within WHO-organized networks.

Recommendations Against Travel Bans

Trump took particular aim at a statement the WHO issued after he banned travel from China. The statement reiterated the organization’s standard position advising against travel restrictions. “One of the most dangerous and costly decisions from the WHO was its disastrous decision to oppose travel restrictions from China and other nations,” Trump said at his April 14 press conference. “They were very much opposed to what we did. Fortunately, I was not convinced and suspended travel from China, saving untold numbers of lives. Had other nations likewise suspended travel from China, countless more lives would have been saved.”

While the WHO never explicitly called out the United States, the organization’s binding regulations require it to issue temporary recommendations after issuing a PHEIC, and advising against travel restrictions is standard advice. At the Jan. 30 press conference announcing that emergency, the WHO stated it “doesn’t recommend limiting trade and movement.” The next day, Italy issued a ban on travel to and from China after reporting its first COVID-19 cases. On Feb. 29, the WHO released recommendations “against the application of travel or trade restrictions to countries experiencing COVID-19 outbreaks.” However, these recommendations also said, “Travel measures that significantly interfere with international traffic may only be justified at the beginning of an outbreak, as they may allow countries to gain time, even if only a few days, to rapidly implement effective preparedness measures.”

The WHO’s recommendations may also be related to the IHR, which prohibits unnecessary restrictions on travel. On Feb. 29, a group of 16 global health law scholars wrote in The Lancet that countries implementing travel bans could be in violation of the IHR. Under Article 43 of the IHR, countries are only allowed to take additional health measures as long as they are not “more restrictive of international traffic and not more invasive or intrusive to persons than reasonably available alternatives.” The scholars also argue that travel bans violate Article 3.1, which addresses human rights and freedoms, by failing to follow international law principles of “necessity, legitimacy, and proportionality.”

A preliminary study indicates that the ban on travel from China may have bought the United States some time to prepare for the outbreak but could not have completely prevented the spread of the disease. A WHO meta-study of previous travel bans shows they have only limited effectiveness in containing outbreaks. Analysis from the New York Times shows that most U.S. cases came from Europe, not China, although the administration hesitated to halt travel from Europe due to economic concerns.

As explained by David Fidler on April 15 in Just Security, “parties do not have to follow the [WHO’s] temporary recommendations, but the IHR requires states parties to provide WHO with the scientific and public health justifications for trade or travel measures that do not conform with such recommendations.”

Additionally, the WHO advises against travel recommendations because they can provide a false sense of security. “It makes the country concerned [focus] more on managing their borders rather than focusing on… stopping the spread within the community,” Margaret Harris, a doctor with the WHO, told The Independent last month. Thus, while Trump is correct in claiming that the WHO advised against his travel restrictions, he ignores the WHO’s guidance that such bans must be supported by public health evidence and should be accompanied by other preparedness measures.

WHO Funding

At the April 7 press conference, Trump stated that the United States contributes the “majority – the biggest portion of the WHO’s funding. While the United States provided the biggest single contribution at 14.7 percent (about $893 million of the WHO’s two-year budget), it does not give a majority. About $100 million per year of those funds goes toward “assessed” services like disease eradication, with about 5 percent of that going toward outbreak control preparedness. The additional funds fluctuate around $300 million per year and are given on a voluntary basis, often going toward ongoing public health crises.

While the United States donates the most (though, again, not the majority) to the WHO’s annual budget, it has not contributed the most to the WHO for its COVID-19 Global Humanitarian Response Plan. As of April 23, U.S. has donated $15 million to the response fund, while Japan had donated $46 million, Kuwait had contributed $40 million and China had provided $20 million.

The president’s April 14 press conference did not clarify when or how the hold would take place. Congress determines the “assessed” appropriations to the U.N. and its agencies, although the funds are directed through the Department of State and U.S. Agency for International Development (USAID). House Speaker Nancy Pelosi called the withholding of funds “illegal.”  However, anonymous administration officials told the Washington Post that the appropriations law may allow him “to spend the remaining $60 million on any international organization.” Trump’s budget for fiscal year 2021, issued on Feb. 10, proposed slashing WHO funding from $122 million to $58 million. According to the WHO’s statement of account, the U.S. is already behind on its payments, currently owing $198 million to the organization.

Conclusions

The WHO has been severely criticized, even by some of its supporters, in its early handling of the COVID-19 outbreak. However, even before considering the proportionality of Trump’s halt on aid during a pandemic, his justifications for cutting off funding to the WHO exaggerate the case. The WHO began efforts to combat the coronavirus in January, well before the highest levels of the Trump administration took the threat seriously. The president was correct that the WHO repeated false claims from China early on, but it’s unclear whether calling out the Chinese government would have led to a more successful response. Finally, while the WHO did recommend against travel restrictions, Trump neglects to mention that the advice was given in the context of the organization’s strong emphasis that the most important early measures should be to isolate, test, and trace, and that the IHR rules themselves, which the United States led the effort in drafting, arguably support the WHO’s position on travel bans.

The WHO has also worked to combat the coronavirus outbreak through other means. It has encouraged countries since January to focus on diagnostic and contact tracing capacity. It fought against disinformation, working with Facebook, Twitter, and Google to direct users to official sites, and it urged global leaders not to promote untested cures. Its current $2 billion global humanitarian response fund is focused on combating the virus “in some of the world’s most vulnerable countries in a bid to protect millions of people and stop the virus from circling back around the globe.” As of mid-March, the organization had provided 1.5 million diagnostic testing kits to 120 countries. Most recently, it began coordinating global vaccine development. That’s not to mention the other lifesaving work the organization performs in different corners of the globe. Withdrawing funds will not fix the mistakes the WHO made, but it will jeopardize many of these ongoing efforts.

IMAGE: (L to R) French President Emmanuel Macron , US President Donald Trump and Director-General of the World Health Organization (WHO) Tedros Adhanom  after posing for a group photo on the first day of the G20 summit in Hamburg, northern Germany, on July 7, 2017. (Photo by SAUL LOEB/AFP via Getty Images)

 

About the Author(s)

Jared LeBrun

J.D. student at Yale Law School, former intern at the Department of State, the Department of Energy, and the law firm Covington & Burling.