Virtual Meeting

What's Next for the World Health Organization?

Wednesday, December 16, 2020
STR/NurPhoto via Getty Images
Speakers

Professor of Global Health Systems, Harvard T.H. Chan School of Public Health

Distinguished Visiting Scholar on Global Health, Harvard T.H. Chan School of Public Health; Former Assistant Secretary for Global Affairs, U.S. Department of Health and Human Services; CFR Member

Assistant Professor of Global Health Policy, London School of Economics and Political Science

Presider

Founder and Chief Executive Officer, Pandefense Advisory; CFR Member

Panelists discuss the state of the World Health Organization, including the influence exerted by the United States and China, the organization's ability to coordinate a global vaccine, and its role in addressing future pandemics.

BRILLIANT: Good morning. Good afternoon. Good evening, wherever you are. My name is Larry Brilliant. I am a member of the Council and I have worked over the years for WHO. Ten years as a medical officer in smallpox eradication, polio eradication, and blindness, and over the last thirty years as an advisor in one form or another. It's really a pleasure to be with you today. I'm so pleased that the Council has taken on the challenge of talking about what's next for the World Health Organization. The panel that we have today have all worked with WHO, around WHO, in WHO, for many years. It's a pleasure to introduce Rifat Atun, who's a professor of global health systems at the Harvard Chan School. He was also the director of strategy for the Global Fund, worked for the World Bank, worked for WHO, many years in executive positions. Nils Daulaire, my friend, who is a distinguished visiting scholar on global health at Harvard, former assistant secretary for global affairs in the Department of Health, and he served on the WHO executive board. We'll be able to blame him for most of the bad things that happened to WHO, I'm sure. And also a pleasure to introduce Clare Wenham. Clare is an assistant professor of global health at the LSE. She has advised the European Parliament, UNFPA, UN Women, the Asian Development Bank. And all of us have worked around the orbit of WHO.

I'm going to start off with some brief introductory remarks for those of you who may not know the structure or history of WHO. And then I'm going to start asking the panelists some questions, they'll ask each other questions. We will talk for about thirty minutes, and then we will open it up for questions from all of you, which of course, is the most important and often the most entertaining part of this session. So first, the structure of WHO is not really understood very well in the United States. It is a member organization with 194 member states. WHO is the secretariat for that membership. In many ways, it is not different than the membership itself. It makes decisions through its executive committee, as well as its annual meeting of the World Health Assembly. Every year it takes about two votes that are formal votes—they're usually on Taiwan and on Palestine. Virtually everything else is decided by consensus. If you were doing a startup right now, you would have to ask yourself, do you want to create an organization that has your critics, your customers, your employees and your investors, all on your board of directors, each with one vote? If you can hold that idea in mind, that's not dissimilar to the structure of WHO.

WHO's annual budget is about equal to the University of Wisconsin's Medical Center or the annual health budget of a city the size of San Francisco—it's $4 billion. Of that $4 billion only 20 percent is core funding for the original mandated tasks of WHO. 80 percent comes from philanthropists or other organizations and could be thought of almost as donor-directed funds because with that money comes mission creep. With that money every year comes assignments that have to be carried out. I think it's important to remember the successes of WHO. We will be lamenting its failures, but smallpox would not have been eradicated had it not been for WHO launching the largest United Nation peacetime army in history. We would not be where we are in polio eradication, over almost two decades, unremitting, getting down to a handful of cases in one country right now without WHO. The blindness program would not have succeeded. And we undoubtably, with all the difficulties that we've had with the multiple outbreaks of Ebola, it would have been far, far worse without WHO.

When I mentioned in a call with WHO executives that I was very happy to hear from the Biden transition team that they would be rejoining WHO, the response was quite curious, they laughed. And they said, well, of course, the U.S. has never left WHO. What you've done is issue a press release that you were considering divorce. But the divorce papers have not yet been adjudicated by the magistrate. And the issue certainly has not reached a full divorce, but we're really happy that you will rescind the press release. And you are so much welcome back at the organization that you've never left. And with that, I thought I would start off, Rifat, with you, and ask you because working with one of the major funders of WHO, the Global Fund, working with three specific diseases that the Global Fund prioritizes, talk a little bit about your relationships with WHO, working relationships with WHO, successes and failures, and help us answer the question what's next for the World Health Organization from your point of view?

ATUN: Thank you, Larry. Yes, in fact, when I joined the Global Fund executive management team, Global Fund was hosted by the World Health Organization. So all our administrative processes were WHO processes. And I found this to be extremely bureaucratic. In fact, our board made the decision to leave WHO and to establish Global Fund as an independent entity, because we just did not have the agility to respond to country needs quickly enough. And I think herein lies the challenge. In terms of WHO, there are issues in relation to function, in relation to focus, in relation to form, and also in relation to financing, some of which you have identified. The first, in relation to function, the number of functions the WHO performs are many—technical agency, normative agency, providing support to countries. The problem is that there's limited focus on what WHO should be doing. It has really over the years, the mandate has expanded from a number of core activities to now very much a sort of donor-driven agenda. And as you said, all with very small budgets. So even where there is the willingness, there isn't the capacity, nor the financing. But the form itself is also an issue because the governance is not designed to be agile, it's very bureaucratic. So there's a WHO in Geneva, then there are six regional offices, then there are 150 or so country offices. Now the regional directors are elected by regional committees. So the regional director is accountable to regional committees, not necessarily to WHO Geneva. So coordinating those are very difficult. And financing, as you said, almost 80 percent is voluntary contributions. And that drives agenda. So when it comes to coordinating with other agencies, we had issues because there was always this cash on the mandate. What is the mandate of the World Health Organization? What is the mandate of Global Fund? What is the mandate of other UN agencies in responding? Who sets the technical agenda and who implements? So the global architecture is very, very crowded. And that was one of the big challenges to try and precisely define what we were doing and what WHO was doing.

BRILLIANT: Rifat, of course, one of the primary architects of that structure was the United States in the formative years of WHO. Would you say that WHO is structured for success or would you say that it is structured for failure?

ATUN: Well, the way it is structured, it is really not designed to be a giant and not to respond to major emergencies quickly enough because, as you said, it has a committee structure. It takes quite a long time to come up with a decision. It is not really designed to be an implementing agency. Now, what it does as a technical or a normative agency in defining global guidelines, defining sort of global goods on surveillance, I think those functions are done very well and WHO is a highly respected organization, but it is not really an agile entity that can implement decisions especially in relation to very complex challenges, such as COVID-19. I mean, you mentioned smallpox. Of course, there's been success with a number of vertical programs, but the kind of challenges we face now—noncommunicable diseases, COVID-19—that involve not just health, but also many other factors that influence health are very difficult to manage by an entity whose primary focus is on health. So I think we need to rethink, is the structure fit for purpose? And B, what is the purpose? What are the core set of functions, but also what is the focus? Because you can have a set of functions but across very many areas and this is the challenge, because WHO is now involved in education through a new academy. In fact, there has recently been an entity established for innovation, which seems, sort of, almost oxymoronic. Innovation in a highly bureaucratic entity cannot really happen. So I think that focus is critically important. But that said, WHO is very important and needs to play an important role going forward. The question is in what shape and size and through which functions that is achieved?

BRILLIANT: Nils, you've got a unique vantage point. You've been inside on the executive committee of WHO. You've been outside from the State Department point of view, as well as when you ran the Global Health Council. Can you give us that insider/outsider perspective?

DAULAIRE: Well, WHO's prioritization and decision-making is extraordinarily messy. And that is a very clear reflection of the world in which WHO operates. It is not unique in its dysfunction in that respect. But I think one of the key issues that I observed, both from the inside and the outside, was that WHO does not have a single governance structure. I sat on the executive board, and that was one of the governance structures speaking on behalf of the member states. But in fact, WHO has a multitude of governance structures, donors, great power issues, which we're certainly seeing now with China and the United States. The regional structure of WHO, with independently elected regional directors, who owe no allegiance to WHO worldwide headquarters in Geneva. And a multiplicity of political and self-serving issues among the electors of the assembly. This is very often a place where senior civil servants from ministries of health go to live out their golden years, and that does not necessarily contribute to the well-being of global health.

So all of those things, I think, are important issues that need to be addressed. And I would say that a number of things, you've talked about the 20 percent/80 percent split, I think if WHO is going to be successful in the long run, it needs to have a budget that is much more closely aligned with both priority setting and with the sources of that budget. One of the things that, sadly, the United States has been an obstacle towards is raising the core budget of WHO, which I believe should be no less than 50 percent of its total operating budget, which then makes the decision-making that takes place in the formal structures far more meaningful. Otherwise, it is very often a group of resolutions that have no teeth and never actually get carried out. And that would be one important thing. Another would be to reflect within the governance in a formal way, the role of non-governmental actors who are increasingly important in today's world. WHO was established in 1948, and at that point it was probably fair to say that governments were the key actors in health issues around the world, but that is no longer true. So that needs to be changed. I think doing away with the regional election of regional directors and making the regions much more closely linked to WHO headquarters in Geneva would help a great deal in terms of bringing unity into this. And then finally, the fundamental issue of one country, one vote is, I think, a fundamental flaw of WHO. 194 votes at the World Health Assembly, each one carrying, in principle, equal weight, there needs to be a restructuring of that not to reflect the great powers as much as to reflect perhaps a regional set up in which each of the current regions of WHO have a certain weight in that decision-making rather than this free for all that we've got now.

BRILLIANT: Nils, that's an excellent list of reforms. And I think WHO, every year, every new director general, goes through a reform process. I think with Dr. Tedros [Adhanom Ghebreyesus], the current director general, you have one of the most reform-minded director generals that we've ever had at WHO. He came into his office with, as he said, a sledgehammer and he has been trying to reform WHO in the midst of these crises. What advice—if you were speaking right to him, he'll hear this, what advice do you have for Dr. Tedros right now?

DAULAIRE: I think he should get a bigger sledgehammer. I think that one of the issues, I don't think there's any question but that the director general of WHO is a critical part of this equation. We've seen good ones, and we've certainly seen bad ones over the years. And the vision and the direction given by the director general needs to be reflected in terms of some of these fundamental reforms. I think, in many respects, he comes with a great deal of strength since he comes from the Global South, the first African director general of WHO and that was certainly a topic of great discussion back during the time that I was on the executive board. And I think he needs to help convince the donors and great powers to ante up to make this greater commitment to the core budget. But he also needs to convince the countries that are on the lower end of the income scale and often have relatively small populations to be willing to give up some of their putative power in terms of this one country, one vote in order to make WHO more functional.

BRILLIANT: Thank you, Nils. Clare, bigger sledgehammer? What advice do you have for WHO? What advice do you have for the people in the Council on Foreign Relations as they think about what's next for WHO. You study and teach about the structure of WHO. Help us to understand that.

WENHAM: Absolutely. And I actually wanted to pick up on something that both Nils and Rifat brought up, because I think it's really interesting having these interdisciplinary conversations. I'm a political scientist. So I look at this from a very different perspective. And I understand that, you know, as health experts and people who've been inside the WHO, you can see these tensions of not being innovative enough, and, you know, wanting to be able to process change quicker and make more functioning institution. But what worries me about that is the fundamental norms of good governance, which we know institutions need to have for people to take them seriously. You know, things like democratic principles of one state, one vote. Things about, you know, transparency and due diligence and due processes, which might take time and might be bureaucratic, but I think they're really important to instill the legitimacy in the organization. I think if a lot was going on behind closed doors and certain donors were driving the agenda, you know, as we've been saying in this call, I think that that risks broader normative concerns for WHO's legitimacy in making these calls if they don't have such processes within them.

And I think that points to a bigger problem within the World Health Organization, which is, as you mentioned, it's a member-state body. It's reliant on its member states agreeing for things to happen. And then it's then beholden to its member states for, you know, the next steps and whether they think it's doing well. And so this talks to a broader political tension that WHO has, which is that it's a technical body. It's a technical organization and the constitution and the mandate is a technical body. I think that's an important point, a sort of side note, which is that it's not an operational or implementational body. It's set up to be a technical organization, and it does that really well. And so saying, well, it's not innovative enough to be able to operationalize, well, that really wasn't what it was set up for. So I think one of the bigger questions is really, you know, what are we trying to get WHO to achieve? Do we want it to be an operational unit? Or do we want it to be able to produce the technical and normative role?

But the problem is, as a technical body, it exists within a political world, right? And so you can see these battles happening, and whether they're happening between regional office and global office, the global central headquarters in Geneva, whether they're happening between, you know, the sort of proxy wars we're seeing between the U.S. and China this year, whether they're happening between, you know, prioritization of particular areas, in particular, their own interests, I think WHO needs to not shy away from the politics. And actually, one of the tensions and one of the reasons it's critiqued is because it sort of buries its head in the sand, because it doesn't want to upset its member states. And that goes back to its position of the member-state organization. But I wonder whether actually engaging with the politics and taking positions and being more forceful would further encourage greater respect for the institution? Because I think one of the real concerns I've seen during the COVID outbreak has been this complete departure from following WHO guidance, right? And from, you're seeing governments all around the world do their own thing and not listen to what WHO is saying, the kind of technical guidance that they're so good at giving. And I wonder whether trying to reclaim some of that legitimacy might come from actually taking a more political stance and trying to kind of claim that space amid that crazy governance that goes on with multiple actors in global health at the moment.

BRILLIANT: You asked, rhetorically, I think, do we want WHO to be a regulatory and normative body? Or do we want it to be an operational and responsive body to emergencies? And of course, the answer is both. And that's part of the mission creep is that we want it to be many things, and those are just two of the many. About four or five years ago, Bill Gates convened a committee with Angela Merkel. It's sometimes been called the Gates-Merkel Committee to advise the G8—then the G8—on how to deal with a pandemic and one of the ideas should one occur. And one of the ideas was that if WHO announced a pandemic or a global health issue of international concern, that would trigger an organ inside of WHO called GOARN, the Global Outbreak [Alert] and Response Network, to become unmoored from the structure of WHO, automatically get a new board of directors that was very political but represented the premier of China, and the president of the United States, and all the real actors and be able to tap a pre-agreed upon line of credit or amount of money at the World Bank in order to respond quickly but to not build WHO's core business around response but to not fail to be able to respond, to do those twin things you mentioned. Is something like that sound of interest to you? Or does it sound completely impractical?

WENHAM: I worry with something like that, and I think it's a great idea to be having these conversations, and I really welcome the fact that such innovative thinking is happening. The risk is you create two parallel mechanisms, you know, the same institution. You have a more mobile institution for responding to emergencies and the kind of daily business of WHO and everything else they do get kind of, you know, stuck. And I guess the question with that is then, you know, how do you navigate between the two, because presumably some decisions will still need to be made by the World Health Assembly, as the, you know, people who have the mandate to actually make the decisions and push through change? And so how do those things interact with each other? And how do you stop that becoming, you know, highly politicized as well within the broader structure? I think it's much better to understand what's going wrong with the current structure of WHO and try and change that if we want an implementing or operational arm, rather than trying to recreate new bodies and new institutions, which is what often happens in global health but they might still be plagued with the same problem.

BRILLIANT: So, we have about five minutes before we're turning it over to outside questions. First, I'd like to ask any of the panelists if you want to comment on what your other colleagues have said.

DAULAIRE: Go ahead, Rifat.

ATUN: So very quickly, I fully agree with what Nils and Clare have said. I think one of the challenges of being a member-state entity, it's very difficult for the WHO secretariat or the technical entities or individuals to criticize a country. And this is problematic because there are some underperforming countries in relation, for example, the provisions of the International Health Regulations. You know, going into the pandemic many countries were not prepared, even though there's a, sort of, international legal obligation. But WHO doesn't have any mechanisms to impose these. In fact, many of the assessments are taken independently by countries with an external observer. And there's no arbitration mechanism whether a country is achieving the level of performance they should in relation to pandemic preparedness. So this is not just a structural issue, it's also a real performance issue even in the areas where the obligation should be very competent and should be empowered to act, such as preparing for pandemics and responding to pandemics.

BRILLIANT: Nils, do you want to also comment?

DAULAIRE: Yes, let me just note that, I think, generally, and this has already been commented on, the WHO is respected as a normative institution. And its normative in two different ways. Its normative technically, but it also plays an important role in developing socio-political norms that are broadly acceptable and agreed to by countries around the world. And it's done that in issues like sexual and reproductive health and rights, and access to health care by disadvantaged populations, and so forth, and trade and intellectual property issues. So I think it plays an important role in both of those. But when you look at the issues of quick response to a global emergency, I simply do not see it as having the structural capability to do that on what would turn out to be more or less an ad hoc basis. These things don't occur on a month-by-month or year-by-year basis. So I would see that WHO really ought to have five key action functions within that context. One is to ring the bell, to identify when something's going on. We have the outline for that with the Public Health Emergency of International Concern, but it needs to be more nuanced, it needs to have more of a spectrum than it does. It's not just on or off. Secondly, it needs to develop, with consultation, the appropriate response steps to what's going on. And again, that's normative. Thirdly, it needs to identify the level of needed resources. Fourth, it needs to host and hopefully chair, the response actions without being the implementer itself. And then fifth, it needs to monitor and report on progress. I think by doing those five things it plays to its strength without trying to develop a capacity that I think would be challenging at best to establish.

BRILLIANT: Clare, I'm going to give you the last word before we turn it back to Carrie and thence to questions.

WENHAM: There is so much we could pick up on with everything that's been said. I was going to pick up on one thing. The comment you made, Nil's, about needing a more nuanced approach to the Public Health Emergency of International Concern discussion. I think the worry is if you look at other governance mechanisms, which have introduced phased tiers or phased approaches to responding to emergencies, such as the UN humanitarian program or the FAO, the food, security, and famine program, you know, nothing really happens until you get to that red level. And so what would happen is you might just have lots of outbreaks, which are amber for a long time and no one really does anything. And so, I think, it's more trying to answer the question of, well, why, you know, I don't think the problem is with the alert, I think the problem is with their response. I think that WHO rings the bell and then governments don't do anything. I think that's the question that needs to be tackled. And so whilst I think the IHR need to, you know, have revisions to them in some form or other, I think the question needs to be, you know, are we are we answering the right questions with those revisions that are being proposed? Are we actually solving the problem or just, you know, sticking plasters where they don't need to be stuck?

BRILLIANT: Thank you. Thank you, all three of you. And now I'm going to turn it back to Carrie and the members will have a chance to ask questions, so hang on to your seat belts.

STAFF: [Gives queuing instructions] We will take our first question from Katherine Hagen. Please accept the "unmute now" button.

Q: Thank you so much and excellent discussion of the challenges facing the WHO. I worked for many, many years in Geneva with the ILO, a parallel organization in the UN system to the WHO but also got very much involved with the WHO through the Global Health Council, Nils, so it is very good to see you participating in this discussion. But I did appreciate each one of your comments and would like to have you talk a little bit more about two particular challenges. First of all, since the WHO is a UN agency, much like the ILO and others like it are, to suggest a substantial increase in the assessment rate for the WHO without looking at its relationship to other UN agencies may create a problem in terms of actually getting to that level. But secondly, I think Nils has brought out and, I think, Rifat talked about, the challenge of multistakeholder engagement in the WHO and the fact that in terms of the HIV/AIDS issue, you needed to have a Global Fund that would be parallel to it. What's wrong with coming up with multistakeholder programs that are like the Global Fund and spin off in different kinds of ways rather than depending entirely on the WHO for these kinds of operational programs that would depend on a big budget increase in order for the WHO itself to do it?

BRILLIANT: Thank you, I think we'll let Rifat answer that question. That's right in his wheelhouse.

ATUN: Yes, thank you, Katherine. I think this is a really excellent suggestion. Again, WHO's strengths are really in the, sort of, normative and the technical capability that it has. It is a highly respected agency. So at the Global Fund we work very closely with WHO and we draw on the guidance from WHO, but implementation was actually done by countries. We acted as a funding agency but not an implementing agency. And having both at the board level, but also at the country level, a multistakeholder governance structure was invaluable, including both to donor countries, recipient countries, as well as civil society, affected communities, private sector, as well as foundations. That really incredibly increased the richness of the discourse and held us to account. As the secretariat we had to perform. Our board really held us to account. And if we're underperforming, this was very openly said in the board meetings. And that structure was reflected at the country level. And I must say, at the Global Fund, one of the most important reasons why Global Fund has been successful is the civil society, both in the governance structure but also at the country-level implementation. So I think new entities working with WHO on the implementation that are much more inclusive and that are much more diverse would be a very strong addition to the current architecture. And WHO can play a coordinating role to bring these entities together to ensure greater effectiveness in integration and implementation.

BRILLIANT: I would add that the trend towards more engagement from civil society, from non-state actors, from NGOs has been slow, but it has been consistent. And I offer as evidence that prior to 2005–2006, WHO was forbidden to take cognizance, that was the word that was used, to take cognizance to any report of an outbreak of an epidemic in any country unless that report came directly from the minister of health of a member state. And in 2006 with the new international health and sanitary regulations, it was opened up so that any of the new digital reporting systems, any NGOs, any nonprofit, any citizen group, any individual citizen, could appeal directly to WHO to take action. That added a level of openness and a level of additional work. But it's just one example of, I think, what Rifat is talking about by bringing multistakeholder action. Can we have the next question, please?

STAFF: We'll take our next question from Jim Kolbe. Please accept the unmute now button.

Q: Hello, this is Jim Kolbe with the German Marshall Fund. The World Health Organization is primarily an organization focused on health issues worldwide and not political issues. In order to participate again in the World Health Organization, would it not be unreasonable for the Biden administration to say to the World Health Organization, you have to allow countries such as Taiwan back into the organization. After all, they've shown great success in their handling of the COVID pandemic. There's no reason, from a health reason, to exclude countries like that. Shouldn't that be a condition for our participation again in the World Health Organization?

BRILLIANT: That's a very easy question, so I'll turn that right over to Nils.

DAULAIRE: Thank you. Nice to hear your voice. Jim. The challenge here is that, I think, Larry mentioned at the beginning, that there are only two votes taken in every World Health Assembly and that is should we allow Taiwan to be seated and should we allow Palestine to be seated. In my mind, anyone who represents a meaningful population that has health issues, ought to have a seat of some sort that the World Health Organization, ought to be heard, and ought to be part of the discussion and debate. There may have to be some nuancing done to get through some of the international politics of that, but I would certainly agree with you that simply excluding and pretending that certain populations don't exist, does not work to the benefit of global health.

BRILLIANT: Yes, and obviously in a pandemic, if the disease is anywhere, it's everywhere. So it's foolhardy to exclude from the conversations any place that the disease could be, any country, or any location. But the politics are, as we've all talked about, they reign supreme. Next question, please.

STAFF: We will take our next question from Catherine Bertini. Please accept the unmute now button.

Q: Thank you. Hello, I'm Catherine Bertini with Syracuse University and the Chicago Council on Global Affairs. Thank you for this very frank discussion, most appreciated. Three points that I'd appreciate your comments on. One, in terms of reform of WHO, the director general really can only reform internal matters, can he not? I mean, the real big issues that need to be tackled are governance issues and those must be tackled by governments. Is this a role that the Biden administration might take on, whether they do or not, who might take on governance? Number two is, absolutely, we need to have a normative function and an emergency function. Do they both have to be a WHO? If it's considered impossible to put them together, would the Global Fund be or UNAIDS be examples of how to do something different in order to handle the emergency process separately? And then three is regarding pandemics. WHO's mandate is health. Pandemics is everything. And the minute it becomes a pandemic, then Ellen Johnson Sirleaf or Boris Johnson or whoever is in charge in their country, not the health minister. So why should we not have some sort of an international function like that? Thank you.

BRILLIANT: Clare, would you want to start with those and if you leave anything off or want someone else to take on? But otherwise, they're all yours.

WENHAM: Thank you so much, Catherine, for those questions. I think they're really important. I think the first one is the one I'm going to start because, absolutely, that's a problem, right? Even if the WHO director general, or any, you know, group within that subgroup within that proposes reforms has to be routed of by the WHA. And particularly when it comes to issues that were talked about in the first, kind of, session about, you know, any type of sanction or mechanism to ensure that governments behave a certain way in the case of outbreaks. Governments aren't going to vote for that in the WHA. No government's going to vote for something which gives them less power and gives WHO more power. So you're in a catch-22 where from the best public health approach you need WHO to have power, but in the reality of a Westphalian system we live in, governments are the ones that have the power and making those decisions are really tense. I think this is where we need to have, you know, a consensus amongst member states that they're willing to do that and, you know, you're saying which other institutions or actors might take that on, I think the Biden administration could or might, although I think it's important to remember that the global health landscape isn't the same as it was in 2016. And, you know, I think there are increasingly new leaders in global health. I don't think it's going to revert back to, you know, U.S.A. all the way—I can say that as a Brit on the call.

But also, you know, I think, look at places like Germany and Finland and, you know, other actors that are really coming to shape and I also think let's look at the actors who've done really well in COVID as new leaders in global health, you know. We should be the following people who are putting evidence into action and showing us the way. But I also think actors maybe like the G7, G20, could be people who get behind reform mechanisms and encouraging new governance actions as well. And, absolutely, your question about pandemics and the going on beyond health is 100 percent true. And that's a problem. And you know, even if you look at things like pandemic response plans, panel preparedness plans, they only focus on the health. I've been spending a lot of time recently reading various kind of response plans again, and the narrowness of the scope is quite concerning given everything we know about the knock-on effects of outbreaks. And that's not new. We didn't just learn about the socio-economic impacts of outbreaks in COVID, right? This goes back to the eighteenth century when the international scientific conferences were set up to balance the impact between trade routes of health. So we know that that intersection happens all the time. But the plans we put in place are really narrow. And I think that means we need to think beyond, but I don't think that means that WHO is defunct. I think it means we need more activities across the UN system and across governments and the kind of whole of government approach to anything.

BRILLIANT: Rifat, the caller asked about the Global Fund, and so I'd like you to comment. You were the head of strategy there.

ATUN: Yes, indeed, an entity such as the Global Fund can play an important role in bringing together different actors and they have done so. So a broader remit than what WHO has in terms of just sort of in terms of focusing on health. But in relation to reform, the Global Fund was able to reform and it changes often. But with WHO that has been changing because for twenty years there have been initiatives to reform WHO starting with the Brundtland administration. So there's a lot of energy, there are studies, there are suggestions, but then it is difficult to introduce change. I think one has to take a step back and say, why is that? Well, I think the donor countries, the major donors, really, if they do want reforms, they should step up to the plate. They're the major funders, and part of the funding could be conditional on introducing and achieving certain reform targets. And especially as 80 percent of the funding is sort of voluntary, I think there's a very important sort of instrument that can be used to introduce reforms. To ensure that WHO focuses on sort of on its core mandate and the focus and the capabilities are not diverted into multiplicities of areas and presenting WHO as a very difficult agenda to manage. And I think the time has come and I think a clear suggestion, the G20, could play a very important role. And it will also give G20 a real purpose.

DAULAIRE: Let me just comment briefly on one of the issues that Catherine raised, which was what role the Biden administration should play on this. We've just come through four years of the United States trying to be a bully on the world stage. I don't think the Biden administration has the interest in being a bully even in moving in the right directions. I do think that playing an active role in working with like-minded countries, in pulling together serious reform proposals but not saying this is the U.S. position and take it or leave it, is going to be an important part of how they proceed.

BRILLIANT: Thank you. I want to make one addition, which is in talking about pandemics, the idea of defaulting to a president or premier of a nation state. And that's what it is, it's defaulting to it. It doesn't work. Because of all the things in history that require global collaboration, a pandemic is right at the top of that list. In fact, if you were to ask me why you need a United Nations, peacekeeping, and safety, and the Security Council would probably be at the top of my list. But number two would be communicable diseases that accomplish the scope of a pandemic. So it has to be more than just leave it up to the countries. And of course, with 194 countries, I'd like to see the first country that stands up and says, yes, I'm willing to give up a little of my sovereignty in order to achieve a better world. And that, of course, is at the core of the dilemma of the structure of WHO. Could we have the next question, I think we have about thirteen minutes more.

STAFF: We'll take our next question from Thomas Novotny. Please accept the unmute now button.

Q: Hi, this is Tom Novotny. I'm at San Diego State University, but I had the pleasure of serving on the executive board for the WHO from the United States in the Clinton administration and the early part of the Bush administration. And I wanted to revisit Nil's comment about the budget and possibly raising the level of assessment so that the core budget goes up to 50 percent or so. One of the most important barriers on that is, of course, the U.S. and its domestic law that requires zero nominal growth for the specialized agencies of the UN, including the WHO. And until that changes, and I think most people don't realize that it's really, you know, part of the job of the U.S. representative to diplomatically restrain any efforts to raise the level of assessments and to provide more of this core budget at a higher level than 20 percent. And so I wonder if you could comment on the process there and whether or not there's any energy, and this would come actually from Congress, whose job it is to supply those funds through the Senate Foreign Relations and other, sort of, the funding agencies of Congress, in any way differently in the future. And you know, this, I think, has a great deal of bearing on whether or not that core budget could change.

BRILLIANT: Thomas, nice to hear from you. Is there someone you'd like to direct that question specifically to?

Q: Yes, to Nils, of course.

DAULAIRE: Thanks, Tom. Nice to hear your voice as well. So, I 100 percent agree with you. This is a problem of our own making, our being the United States government. The zero-nominal growth, which came about I think in the 80s, and has been really a handcuff on not only WHO, but a number of international multilateral institutions, is profoundly misguided in today's world. And I think it will be an important part of what I hope will be some of the Biden administration's priorities that can be reexamined to see what kinds of flexibilities can be put in there. I know that every time that I went forward to look for ways of increasing the U.S. contributions, the assessed contributions, or to get a higher assessed contribution budget for WHO, the response that I always got from the responsible office at the State Department to international organizations was we are given X amount of budget by Congress to pay for everything in the UN. If you want more for WHO, we're going to have to give less to X, Y, and Z. And so this becomes a profoundly dysfunctional zero-sum game. And I do think it's time for Congress to take a serious look at this in terms of the negative consequences on our own country's health and on the world's health.

BRILLIANT: I would ask everybody at the Council and listeners just to put it in perspective. If 20 percent of a $4 billion annual budget, [inaudible] any budget, by the way, if we're looking at less than a billion dollars in core funding, and we think that this pandemic has cost us somewhere between 3 and 7 percent of global GDP, we're talking about high single-digit trillions of dollars. Surely, it is unwise to not increase the funding of WHO at least for those diseases that have such knockdown, negative economic effects. And any country that does not see that straight line relationship between increasing the core capacity of WHO to deal with these is pennywise and dollar foolish. May we have the next question, please?

STAFF: We will take our next question from Margaret Karns. Please accept the unmute now button.

Q: Thank you. This is Margaret Karns from the University of Massachusetts Boston. And my question I will leave open to which of you or a couple of you might want to answer really has to do with whether you think the current pandemic provides the political impetus, perhaps, for putting more authority into mechanisms for WHO responses and for compliance with the IHR, as well as for preparations for responses to future outbreaks? Do we have a situation where there's now the impetus, perhaps, for some of the changes that you've talked about?

BRILLIANT: Margaret, I'll start with that and leave it open for other panelists. You know, after the Second World War, when we collectively saw the skeletons coming out of the concentration camps and we saw the mushroom clouds over Hiroshima and Nagasaki and the firebombing of Dresden, it seemed as if the world looked and said, we've looked over the precipice and we don't like what we saw. We don't want to ever do that again. And it was like a [inaudible] after the monsoon, the proliferation of the acronyms—the Security Council, WHO, Bretton Woods, the World Bank, FAO, UNICEF, UNESCO—it was a flourishing of international agencies and global cooperation, and NATO, and SEATO and all the different alliances. That was a moment, I think, where a disaster created centripetal force. It was like that after the 1918 pandemic, although it's impossible to disaggregate the effect of the First World War and that pandemic since they overlapped. This pandemic offers us that opportunity. But this is an era of nationalism, not of globalism. This is an era of centrifugal forces tearing us apart—divisive forces. It remains to be seen whether we have the will to seize this opportunity. But, of course, people who never thought about other countries and never thought about our mutual benefit of working together, have certainly turned their mind to it. Our writers, our artists are leading us. Whether our politicians will follow, that's entirely another matter. But I'd love any of the other panelists to comment on that.

WENHAM: I think, yes and no, is the answer. And I agree with what Larry's just said. I think there's going to have to be some change, right, with the IHR. We've got the IHR, in theory, they're there to prevent outbreaks. And they haven't worked or haven't worked up to scratch, so something needs to change within them. Now, my personal view is that the IHR is too focused on preparedness and not enough on response. And that might be one of the tensions within it. I think there are multiple other tensions with them. But I agree with Larry, which is that the method of how we're going to do this. So, you know, there's some calls for new institutions to do this or new mechanisms to do this, which I don't necessarily think will solve that problem, because I think the problems are much more structural and political. I think the question remains, as you know, do we risk more by trying to change them? Do we risk losing more in the current political context where we have nationalist governments, where we have, you know, governments who might want to not have the goodwill that they had in 2003 to '05 when the last ones were being revised? And so is it the right time, and that's when you can start thinking about other ways of revising so you're not reopening the treaty of the IHR, for example, but you know, looking at the biological weapons convention REFCON model of, kind of, continual updates and reflection to create new ways of improving without reopening and risking actually coming out with a deal that is worse than what's currently there. So, I think we do need to think about it, but we shouldn't rush into to doing it before we know exactly what the best way to do it.

BRILLIANT: I think we'll go then to the next question. We've got five minutes left. That's enough for at least one more question.

STAFF: We'll take our last question from Allen Weiner. Please accept the unmute now button.

Q: Hi, Allen Weiner from Stanford Law School. Thanks very much for a tremendous discussion. I do some work here on comparative analysis of international organizations for another organization that I won't name and part of what comes through from that comparative analysis is that these challenges that you've described with organizational governance, the one state, one vote problem, the decision-making only at an annual meeting, the relative paucity of funding of the assessed budget compared to voluntary contributions and what that means, bureaucratic decision-making between meetings, these things are actually common to a lot of international organizations, which are all having reform processes and analyses. And so I guess my question would be maybe for, for Clare, who also has looked at this comparatively, what organizations do operational responses better and why? So I've heard about World Food Program with respect to humanitarianism, but other humanitarian organizations don't get such a great rap either. And so I'm wondering, again, if Clare or others have a sense of which international organizations are better dealing with operational challenges? And what is it that makes that possible? Thank you.

BRILLIANT: Clare?

WENHAM: I'm not an expert in other international organizations. So I wouldn't necessarily want to jump in and say which ones are good. But I think if we look at outbreaks currently and particularly looking at the pandemics and epidemics, the operational activity happens through medical humanitarian organizations, right? You have actors like MSF, and you have Save the Children, and the International Red Cross doing a lot of the operational work. And you have government, right, government medical facilities and provisions and public provision of health that way. And so that's where the operationalism comes in. I think the problem is maybe those aren't talking to each other enough, right? But you have different silos of response. So you have the kind of medical humanitarian response happening over here. And you have the decision-making happening in WHO over here, and maybe there's not enough interaction between those two, because there's capacity in the broader system but, you know, in a kind of WHO, WHO must lead the response. You know, health emergencies, health humanities program creation hasn't necessarily got a key role for those other actors, and there's other non-state and state actors. So I think it's more just thinking kind of more holistically about what's currently there rather than trying to look at new mechanisms itself.

ATUN: Maybe, if I may add to that, it's not just the international organizations that are part of the response. If you look at the Global Fund and Gavi that have been able to invest very substantially to scale up implementation of interventions at country level for HIV, AIDS, tuberculosis, malaria, but also vaccine-preventable conditions. Their funding agencies have enabled a multistakeholder coalition of actors at the country level, including international agencies to monitor collective response. I think that's the critical ingredient is inclusive, diverse, and a coalition of a group of different entities, including civil society to monitor the response at the country level. So it should not be the international agencies doing this. If not, international agencies should enable them to empower countries to do that and develop capacity to respond to these emergencies.

BRILLIANT: I think we could take this one conversation alone into a whole new Council on Foreign Relations activity. I'd like to thank our panelists. Thank you so much for joining us. I'd like to thank our hosts at the Council on Foreign Relations. And most of all, I'd like to thank the participants for your questions. This has been really a good conversation. It's a beginning, not an end, to the question of what does WHO do next and how do we see it in the future. Thank you all very much for attending.

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