Is it time to overhaul the WHO and the UN?

IN the wake of World War II, nations came together as never before to try to prevent future catastrophes on that scale.

The United Nations (UN) was established, along with its array of international agencies, while the European Union helped bring unprecedented peace to that troubled continent.

This was no utopia: the Cold War dominated international relations for decades, bringing with it the ever-present threat of nuclear annihilation, and there was no end to war, genocide, or acts of terrorism.

Nor have those international institutions themselves been perfect. The UN system, with its bloated bureaucracies and competing national agendas, has often been criticised for its inability to act at times when action has been imperative.

Still, for three-quarters of a century, we have benefited from unprecedented global cooperation across health and other areas and, in comparison with the blood-soaked sweep of human history, relative peace.

Now, there are troubling signs that era could be coming to an end as some of the world’s wealthiest countries turn away from international collaboration to focus on what they see as their national interest.

In July, the US formalised its intention to withdraw from the World Health Organization, raising fears the fight against the current and future pandemics could be seriously undermined.

The American Medical Association called for the decision to be reversed, saying it was “a major setback to science, public health, and global coordination efforts needed to defeat COVID-19”.

“The WHO plays a leading role in protecting, supporting, and promoting public health in the United States and around the world,” the association said. “The agency has been on the frontlines of every global child health challenge over the last seven decades, successfully eradicating smallpox, vaccinating billions against measles, and cutting preventable child deaths by more than half since 1990.

“Now is the time to invest in global health, rather than turn back.”

Whether the US will succeed in its aim of leaving the WHO by July 2021 remains to be seen, but the move reflects a resurgence of the simmering isolationism that has long haunted the country’s international relations.

It is also linked to the current US administration’s disregard for science and expertise, seen in its sidelining during the pandemic of another organisation with global impact, the Centers for Disease Control and Prevention.

No organisation is above criticism, and there’s a widespread view the WHO could do with a shake-up.

“COVID-19 has revealed shortcomings in WHO’s powers and funding, warranting substantial reforms,” a group of US researchers wrote in The Lancet in August 2020, noting the agency’s limited ability to independently verify official state reports or ensure compliance with international regulations on epidemic preparation and response.

Nonetheless, they argued US withdrawal would cause major disruption and damage, making Americans (and presumably the rest of us) far less safe.

Some suggest we might need more than an overhaul of the institutions we already have.

Harvard economist David Cutler questioned in JAMA last week whether organisations like the WHO could adequately respond to what he calls the “pandemic era” with a new normal of actual or potential pandemics every 2–3 years.

“Many international organizations work off a lowest common denominator standard in that all must agree before anything is agreed,” he writes. “This type of system does not work when tough decisions need to be made.”

Professor Cutler makes the intriguing suggestion a better model might be found in the North Atlantic Treaty Organization (NATO), the group of wealthy nations that came together in the attempt to regulate nuclear weapons in the wake of World War II.

His argument that wealthy countries need to be prepared to foot the bill for the fight against pandemics is convincing: “The cost is trivial relative to the cost of repeated pandemics,” he points out.

Less convincing, though, is the implication less wealthy countries could as a result be excluded from the decision-making process. It’s hard to see public health measures being successful without genuine buy-in from all involved.

And Chinese leaders probably wouldn’t respond well to his suggestion international airlines should be banned from flying into Wuhan and other places with wet markets.

For all the flaws of the UN system, we need international health bodies that enjoy broad support and are not seen as pushing the agenda of a few powerful nations.

Achieving that, while also ensuring those bodies can be nimble and effective, will be quite a task, but it’s one we can’t afford to fail.

Jane McCredie is a Sydney-based health and science writer.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.