[Editor’s Note: This article is part of a Just Security series, COVID and International Law. All articles in the series can be found here.]
The World Health Organization (WHO) has been battered by criticism during the COVID-19 pandemic. The Trump administration attacked the organization’s response and announced that it would withdraw the United States from the body in July 2021 (a pledge President-elect Joe Biden has promised to reverse). Other U.S. politicians, including New York Governor Andrew Cuomo, have also been critical. And some world leaders have alleged that the WHO has been too credulous toward China. Japanese Deputy Prime Minister Taro Aso, for example, said in April that the organization looked more like the “Chinese Health Organization” than the World Health Organization.
Defenders of the WHO point out that, while it may have been slow to declare COVID-19 an international public health emergency in January, it responded rapidly in other ways, sending a team to Wuhan earlier that month to assess the situation and urging countries to prepare for the likelihood that the disease would spread beyond China. The WHO has had other successes, too. It has worked with social media companies to combat the spread of misinformation about the virus. It has organized large international trials of potential treatments and is playing a major role in COVAX, an initiative to distribute billions of doses of COVID-19 vaccines next year. Criticism of the WHO, moreover, is often a convenient way for governments to distract from their own failures.
Yet the WHO’s shortcomings have been real. As the previous article in this series discussed, the WHO was slow to declare COVID-19 an international emergency, and its International Health Regulations (IHR) were ignored by many states. The WHO also found itself unable to coordinate national responses early on in the pandemic, and it appeared reluctant to criticize its largest members for their inadequate management of the virus. Even before COVID-19, a majority of countries had failed to meet the WHO’s pandemic preparedness standards.
These are largely policy failures rather than legal ones, but some of the blame lies with the WHO’s legal architecture, in particular the toothless IHR, the main rules that govern international cooperation on global health. The WHO is not blind to these problems. In July, it announced an independent review of its response to the pandemic (as well as the responses of individual states). And an internal group is looking at possible reforms to the IHR. Change is overdue.
The Weakness of the International Health Regulations
The WHO’s delay in declaring a “Public Health Emergency of International Concern” at the start of the COVID-19 pandemic reflected not just missteps in the WHO’s response but flaws in the IHR themselves. In 2005, the regulations were reformed in response to the 2002-2004 SARS epidemic, which China was also slow to report. One of the major changes was to give the WHO the ability to use non-governmental sources of information to monitor outbreaks. That was supposed to address state reluctance to report disease clusters for fear that their neighbors would cut off travel and trade in response.
Yet the changes did not go far enough. The WHO still cannot send experts to investigate reports of novel diseases unless the government in question invites them. At the start of the COVID-19 pandemic, it took until February for the WHO’s team to gain access to Wuhan. What’s more, if the WHO receives information about outbreaks from a non-state source, the regulations require it to verify the reports with the relevant government. Thus even though Taiwan, which is excluded from WHO membership, claims that it warned the organization in late December that a new virus was circulating and appeared to be transmissible from human to human, the WHO could not act until China confirmed the reports three weeks later.
The design of the WHO’s alert system may also have been at fault. The regulations create only one level of alert, the Public Health Emergency of International Concern. Without a more fine-grained series of warnings, the WHO may have wanted to avoid pulling its only fire alarm prematurely. Moreover, once the WHO did finally declare an emergency, states did not always abide by the regulations’ requirements.
The WHO’s inability to enforce compliance with the IHR predates the current pandemic. The 2005 reforms required all states to develop and maintain a set of minimum capabilities to detect and respond to potential international public health emergencies. States were originally required to comply by 2012, with less developed countries receiving assistance from the WHO to boost their public health capacities. Yet just 22 percent of WHO members met the deadline, and the WHO has repeatedly granted extensions. Today, 15 years after the regulations were adopted, fewer than half of countries are in compliance. What’s more, although the standards are set by the WHO, governments monitor and report their own progress, and the WHO has no enforcement mechanism for those that fall short.
Reforming the International Health Regulations
Observers have suggested several reforms to the IHR in response to the pandemic. The WHO itself has suggested changing its alert system. In the January 23 statement in which it said that it was too early to declare a public health emergency, the organization suggested that the rules be altered to allow “a more nuanced system” with an “intermediate” alert level.
That is a good idea. Governments may have interpreted the WHO’s decision not to declare an emergency on January 23 as an indicator that all was well, even though the emergency committee stressed that the disease could yet spread widely. A series of stepped alerts would have focused attention on the rising danger, not on the fact that the highest level had not yet been reached.
The larger problem with the WHO is that its legal powers and financial resources do not match its mandate. In August, the French and German health ministries argued that national governments have overloaded the body with responsibilities to serve as both a coordinator of scientific expertise and the first responder to deadly disease outbreaks while not giving it the guaranteed funding or authority to fulfill those duties. The solution, they said, was to boost the WHO’s funding and give its experts independent authority to investigate and assess outbreaks, in order to prevent national governments from hiding potential public health emergencies.
In addition to simply giving the WHO more money, the body’s funding structure also needs reform. Today, just 20 percent of its $2.5 billion annual budget comes in the shape of guaranteed contributions for general operations. The remaining 80 percent is made up of voluntary donations designated for particular projects. In their reform proposals, France and Germany argued for a larger emergency budget, so that the WHO can direct resources at the start of an outbreak rather than going cap in hand to governments during a crisis. Boosting the WHO’s guaranteed funding would also give the WHO’s leadership more freedom to call out its major members when they break the rules.
These changes to the regulations and funding structure of the WHO would require member states to accept obligations that they have, in the past, rejected. But the pandemic may well have changed what’s politically possible. COVID-19 has made clear that without reform, the WHO will be unable to meet its mandate to protect global health. Countries that were once reluctant to empower the body have had a vivid reminder of what happens when it fails.
The Vaccine Challenge
The next big challenge for the WHO will be ensuring the equitable distribution of a potential COVID-19 vaccine. The organization’s efforts on this front are a bright spot, but more will need to be done to help developing countries over the next year or two. The WHO is now a leading player in the COVAX program, which is funding the development and manufacture of nine vaccine candidates. Under the program, once a vaccine is approved, participating countries will receive doses allocated by their population size.
COVAX has proved remarkably successful so far, signing up, as of mid-November, 184 countries and raising its entire $2 billion target for 2020. But the program will not cover all of the developing world’s COVID-19 vaccine needs. More funding will be needed in 2021. And the total doses each country receives will be limited to 20 percent of its population, well below the number most scientists estimate will be necessary to establish herd immunity. That means governments will need to procure additional doses by themselves.
Poor countries may find themselves at the back of the line, behind rich countries with guaranteed national pre-orders. The European Union has agreed to a plan, together with several neighboring countries, to buy enough doses to vaccinate 40 percent of its population. The United States, which, along with Russia and eight other countries, has not joined COVAX, has placed orders for 600 million doses from four vaccine developers. And the United Kingdom, with a population about a fifth the size, has placed orders for 250 million doses. (Most of the leading vaccine candidates require two doses to be effective.)
If it is to ensure that the developing world receives sufficient quantities of any future vaccine, the WHO will need to coordinate more funding and ensure a reliable distribution plan. The incoming Biden administration may be open to joining COVAX (Biden’s campaign did not comment on the program specifically, but it committed to supporting the WHO). U.S. participation in COVAX would mean a big funding injection. Should the United States join, the remaining challenges for the venture will likely be logistical and technical – chiefly producing vaccines in sufficient quantities, and physically getting them to the people who need them.
COVAX is a good reminder that the WHO remains one of the few international forums able to coordinate more than 100 countries around a single goal. Should it succeed in distributing a vaccine widely, it will play a major role in ending the pandemic. That would be a signal achievement of multilateralism, a stark contrast with the world’s failure to work together when COVID-19 first appeared, and a model for how the WHO can and should operate in the future.
Image: (From L to R) World Health Organization (WHO) Health Emergencies Programme head Michael Ryan, WHO Director-General Tedros Adhanom Ghebreyesus and WHO Technical lead head Covid-19 Maria Van Kerkhove attend a press conference organized by Geneva Association of United Nations Correspondents (ACANU) amid the COVID-19 outbreak, caused by the novel coronavirus, on July 3, 2020 at the WHO headquarters in Geneva. (Photo by FABRICE COFFRINI/POOL/AFP via Getty Images)