The WHO and the State of Global Health Governance

Friday, May 1, 2020
Denis Balibouse/REUTERS

Professor, Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine; Former Assistant Director General for Health Security and Environment, World Health Organization

K.T. Li Professor of Global Health and Director, Harvard Global Health Institute, Harvard University

Founder and Chair, Global Health Program, Graduate Institute of International and Development Studies, Geneva

Stewart M. Patrick

James H. Binger Senior Fellow in Global Governance and Director of the International Institutions and Global Governance Program, Council on Foreign Relations; @StewartMPatrick

Panelists discuss the structure of the global health governance system, the role of the World Health Organization, and their perspectives on an effective international pandemic response.

PATRICK: Thank you. Welcome to today’s Council on Foreign Relations’ virtual meeting with David Heymann, Ashish Jha, Ilona Kickbusch, on WHO and the state of global health governance.

I’m Stewart Patrick. I’m the James H. Binger senior fellow in Global Governance, and the director of the program on International Institutions and Global Governance at the Council on Foreign Relations. I’m going to be presiding over this discussion.

I want to remind CFR members and other participants that the meeting is not only on the record but that both the transcript and the audio of the event are going to be posted on CFR’s website.

Now, you all have the bios of our distinguished speakers so I’m not going to try to summarize either their impressive credentials or their contributions to global health, both as distinguished public servants and also as scholars. Suffice it to say we would be hard pressed to try to find a better panel to grapple with this complex and timely subject.

By way of very brief introduction, David L. Heymann is the professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine. He’s also a former assistant director general for health security and environment at the World Health Organization.

Ashish K. Jha is the K.T. Li professor of international health and health policy, and director of the Global Health Institute at Harvard University.

And, finally, Ilona Kickbusch is the founder and the chair of the Global Health Program at the Graduate Institute of International and Development Studies in Geneva, Switzerland. Welcome to you all.

Over the next half hour, my plan is to engage David, Ashish, and Ilona, and then we’ll invite questions from you. It’s pretty remarkable, but we have more than four hundred and eighty-six members and guests registered for this call. So apologies. I’m sure you’ll understand if we don’t get to all of your questions.

Let me begin this with some very brief context. The disjointed global performance in confronting COVID-19 has, once again, revealed shortcomings in the multilateral system’s capacity to prepare for, detect, and respond to pandemics, and the human and economic costs of this are large and getting larger.

Already, and these are probably undercounts, as we know, at least three million people have been reported as infected globally and more than two hundred thousand have died worldwide, to date. In economic terms, the IMF is projecting a minimum 3 percent decline in global GDP for 2020 while warning that much more dire scenarios are also possible.

There’s actually some irony here when you think about it. A hundred and two years ago when the so-called Spanish flu was ravaging the world, there were very few multilateral institutions, which left all countries to fend for themselves. Today, by contrast, we live in a very crowded multilateral landscape, not least in the global health field where WHO, ostensibly, has pride of place.

In the wake of WHO’s problematic responses to SARS and to Ebola, the international health community—excuse me, the international community, instituted significant reforms, which included strengthening of international health regulations and enhancing WHO’s capabilities for emergency funding and deployment.

And, yet, despite these reforms and other initiatives, it has to be said that the global response to COVID-19 has been found wanting and that WHO has, obviously, been in the crosshairs of much of global criticism, not least from the United States.

But there’s, obviously, plenty of blame to go around. Geopolitical frictions and unilateral national responses has also undermined international cooperation including within such bodies as the G-20, the G-7, and the U.N. Security Council.

So in our meeting today and in discussion with our three speakers, I hope we can answer two questions: one, what does the multilateral response to COVID-19 actually tell us about the current state of global health governance, and the second is, in a sense, what to do about it. What should be the priorities for improving global health governance, particularly when it comes to pandemic response?

What I’d like to do first is engage with—start with David. David, looking at the past four months, how would you characterize the quality of the multilateral response, perhaps some of its high points or low points, including an assessment of WHO’s performance? Some people say we should expect more of WHO and others suggest we’re asking too much of it, given its authorities and resources. What’s your take on how it’s done and what it says?

HEYMANN: Well, thanks, Stewart, and thanks for inviting me to be on this panel.

You were talking about reforms in WHO, and one of the reforms that was recommended by a group that Ashish chaired after the West Africa outbreaks was a recommendation that there be an independent technical advisory body to the Emergencies Program at WHO, and that body has been set up and I’m privileged to actually chair that group. It’s called the Scientific and Technical Advisory Group on Infectious Hazards.

So I’ve been very close to WHO but still remaining independent with a group of independent advisors, and in that group we’ve been able to meet with people from all different countries around the world to understand what’s going on in their countries. And if I were to say one thing it would be that despite the geopolitical tensions that are occurring throughout the world, just as WHO has worked in the past during smallpox eradication and other programs, WHO continues to work very well at a technical level.

There’s a free exchange of information from China all the way through to the United States and Europe, Asia, and other countries in Latin America and Africa. That exchange has permitted a rapid understanding of what’s going on in this outbreak. The virus has been clearly characterized, the epidemiology is understood almost completely, and many other things are understood because of informal collaboration and formal collaboration of technical groups with the World Health Organization. WHO has facilitated this collection of people and constantly reviewing what’s going on informally and formally through its external advisory groups.

PATRICK: Can I—can I follow up on that a little bit? Obviously, the International Health Regulations that were revised in 2005 in the wake of SARS attempted to both increase WHO’s authorities, for instance, in declaring a public—a health emergency of international concern, and also required certain country—required countries of the world to, in a sense, build their capabilities for pandemic preparedness, detection, and response.

A lot of folks have suggested that actually there have been some flaws in the way that public health emergencies—the public health emergency process of the declaration actually unfolds as well as, obviously, some continued difficulties with countries, building the sort of baseline capabilities that’s—that you’re sort of discussing. Do you want to comment on that and whether or not there’s anything that can be done about those things?

HEYMANN: You know, the International Health Regulations were developed at a time when communication was very difficult, very different than it is today, and it was aimed at four different diseases: cholera, plague, yellow fever, and smallpox. And the risk assessment was actually done by WHO, and then WHO made recommendations based on what the regulations said.

If, for example, a country reported yellow fever, then WHO told countries you can require a yellow fever vaccination certificate from people coming from that country. So it was a very passive system. Countries reported, WHO said what to do. Fast forward to the revision today it’s a complete change. It’s putting responsibility on countries to develop the core capacities they need to detect and respond to disease and stop it from spreading internationally, and that’s the most important part of the regulations today.

In addition, there’s a safety net—the Emergency Committee—that calls together international cooperation should there be a country that can’t for some reason or other stop an outbreak. So there are two different functions. But the regulations, by having been changed to put emphasis on countries, was a very important move. But, unfortunately, our donor development agencies did not provide the funding necessary for countries to develop their core capacities. They continued to favor issues that they have and not to what governments really want and need to increase health security. So we failed countries in not helping them develop their core capacity.

PATRICK: Yeah. Thank you very much. I’m glad you raised the budget issue and the issue of, in a sense, earmarked funding for what is, obviously, a constrained budget.

Let me turn now to Ashish. You’ve been pretty outspoken in your belief that WHO’s performance is, at least in large part, a function of the attitudes and policies of its member states, who seem to want a more effective WHO but sometimes resist submitting to its authority or even its coordination. How do you think that’s influenced the response to date? And any other reflections you might want to have on the response would be welcome. Thank you.

JHA: So, Stewart, thanks for having me on.

I’m going to start by answering a slightly different question, which is what is the overall global response to the coronavirus, and then talk about global governance and WHO.

I think the thing that we see across the globe—the most generous way you can describe the global response is that it’s been uneven. And that would be generous, because there are some places that have done a pretty good job but most places have done, I think, a relatively mediocre job. And we’ve certainly seen across most Western European countries, with some exceptions, and of course, in the United States, the response has been sort of shockingly abysmal.

And that is an important context, because—and actually the Chinese official response in the early days was quite bad, and then they eventually got much more aggressive. It’s important context because it gets at the question of what do we expect from WHO. What do we expect the global-governance apparatus to deliver for us? And if we said what we expect is for that apparatus to deliver an excellent global response to a pandemic, well, if that’s our metric, we clearly are not doing very well.

But I think that’s the wrong metric. And the reason I bring it up is because, of course, that’s the metric the president of the United States in some ways has used and basically pointed to WHO and said, look, we have this massive pandemic; they were supposed to be in the business of controlling outbreaks, and that didn’t happen, so it’s WHO’s fault.

When I think about what do I realistically expect from WHO, what I want from WHO is transparency and data on outbreaks, a place that can pull information together on what the status of the outbreak is, synthesizing the evidence on kind of what do we know about the outbreak, the causative agent, all the science, coordinating clinical trials, international clinical trials. That’s an area where WHO has a very important role to play.

And then last, but certainly not least, is supporting low- and middle-income countries that don’t have a ton of technical expertise to help them. And there may be other things. But if WHO did those four things well, I would say that’s pretty good. And part of the transparency data is also about sounding the alarm when something serious is happening. And we do expect and want WHO to do that.

So if you look at those, and if you agree that those are sort of some of the key metrics, and ask the question, how has WHO been doing, I would say pretty good; not great, not perfect, but pretty good. So where have there been shortcomings? The shortcomings have been, I think, a bit of overreliance, or you could argue more than just a bit of overreliance, on data from China and from evidence from China. When there was some evidence coming out of Taiwan and other places that there was human-to-human transmission, the WHO said, well, there’s no evidence of human-to-human transmission because Chinese authorities are telling us there is no evidence.

The, I think, excessive praise of the Chinese response, I think, rubbed a lot of people the wrong way, because, however you may feel about the Chinese response, it is certainly complicated and not just worthy of praise.

Those, I think, ultimately, at the end of the day, become nitpicky issues. And fundamentally, the real issue is that WHO has very specific constraints about what it can and cannot do. Those constraints are placed on it by member states. And when the response in individual countries is not going very well, they become a very easy punching bag.

And that’s, I think, what we’ve seen in the United States. And there’s a big kind of group of folks who say, you know, I wish they had stood up to China. And I often push back and say, well, what does that mean to stand up to China? Would it have helped if Dr. Tedros stood up and berated President Xi and called him names and told him he was—no, that would have been completely unhelpful and not what we expect from a multilateral organization.

So there’s just a whole lot of, I think, simple thinking about what we want from WHO. And we want WHO to do those things against other countries, but we would never tolerate it against the United States. And so for me this experience has been clarifying because what it has reminded us is there are certain things we want WHO to do.

I think they’ve done a pretty good job, not perfect, on those things. But there’s a lot of wishful and magical thinking about what we want WHO to do. But we have clearly created an architecture that won’t allow for that to happen. And I think this process has clarified that.

PATRICK: Thank you so much, Ashish. I think it’s really useful to distinguish between, in a sense, the very good technical work that WHO has done and then the very—the huge demands that we have placed on it, in a sense, to be a political actor, to solve some of these geopolitical frictions, and also to, in a sense—you know, it comes up against sovereignty concerns, not least in the United States, but—and also in China.

Ilona, I’m particularly interested in what this looks from a European perspective, where I know people have ideas about the role of the United States and not just the WHO in global-health governance. I’m also curious as to whether or not you see, like both Ashish and David, some bright spots in WHO’s performance and leadership so far.

KICKBUSCH: Well, thanks. And good evening to everyone. It’s evening here in Europe, obviously.

So I think, you know, first of all, the Europeans are surprised and they are annoyed. And Europe is very committed to multilateralism, and they are confronted on very many fronts with an America that it is very difficult to work with, not only in the context of the WHO; also in the context of the G-7 and the G-20 that deals much more with health than it did in the past.

Our experience in the past—and I’m sure David will agree with that—is that, no matter what the geopolitical tensions were, it was possible to bring countries together around health, and particularly when there was an outbreak and a real crisis. And I was involved in evaluating the WHO response to Ebola in West Africa at the time, and one of the most wonderful things in that evaluation was to see how the world came together, how the CDC supported it, how the Obama presidency made extra resources available to help those countries. And geopolitics was not an issue. The world came together to support health.

And at present we see that health—and it’s quite, you know, the opposite; that health is used as a proxy for all kinds of conflicts that are there at the geopolitical level. And that is destructive. So I think that’s the first thing that Europe is finding it difficult to deal with. Of course, it falls into many other things Europe has been experiencing over the last years where the United States has not been supportive of what used to be the transatlantic alliance and has treated Europe more as a competitor than as a partner.

And so all of this is playing into this response and into this debate around the role of the World Health Organization and its performance. You know that most of the European countries, and particularly Germany, but France and Norway—you don’t only have to look at EU countries—are multilateralists, and they believe in the U.N. and they support the U.N.

And you will have seen perhaps last Friday when there was a big event bringing together countries and organizations to support a new effort to accelerate the scientific response to develop vaccines and treatments and diagnostics. That’s—and the major European funders and donors were there—President Macron; Chancellor Merkel; Dominic Raab, on behalf of the U.K. prime minister; Solberg, the prime minister of Norway. And all of them spoke in support of WHO, but even more importantly in support of the global solidarity we need at this point in time for all of us to come together to bring our political clout to the table, to bring our scientific clout to the table, to deal with this issue and, as David has said earlier, to help the low- and middle-income countries tackle it.

And, you know, for people who’ve been involved in the earlier things, like the Ebola, like the SARS, where American institutions and administrations played such an important role, it’s also incredibly sad. It’s really incredibly sad. We miss them. We want them and we need them. And if, you know, for some fight that is going on about totally different issues in the geopolitical sphere, this happens, you know, it’s dangerous. It’s outright dangerous.

And that’s why what we see—and we might talk more about that later—that the European Union that’s now defining itself also as a geopolitical actor is taking very—a very proactive approach, is launching a big fundraising event on Monday. The Germany presidency, starting July 1, will put multilateralism and also WHO there as one of its priorities. So we’re going to see that, OK, if you don’t want to be on our playground, we’re not going to leave. We’re going to try and really move forward and help the world solve this problem.

PATRICK: Thank you. Thank you so much. I think that’s actually—that’s hugely helpful, not least to point out that, you know, in the past, notwithstanding great-power rivalry, there were efforts—there is, in a sense, a global health, and particularly in major pandemics or major diseases—were in a sense bracketed off from geostrategic considerations. So even during the Cold War, of course, you have the United States and the Soviet Union collaborating in the battle against polio. And it’s obviously disturbing when you see these issues spreading over into ones that obviously everyone has a shared—you know, a shared stake in.

Let me just again—once again, encourage members, folks listening to this and watching this, to please ask—feel free to ask some questions so we can get them queued up in—for the discussion to follow. We have about ten minutes until we turn to questions and discussions. I’d like to move now to policy recommendations. Like SARS and Ebola before it, COVID-19 has obviously stimulated a lot of debate about whether we see sort of new arrangements, including for the WHO and its role in pandemic response. And there’s been a lot of different topics bandied about. I’ll just list a few of them before turning to you. One of them is, again, trying to reform the international health regulations to empower WHO in additional ways. Another is sort of doubling down on the global health security agenda to build the sort of capabilities, particularly in developing countries, for basic public health capacities.

Another is whether we should alter the rules on declaring public health emergencies, whether or not, you know, we should move towards sort of different guidelines for things like travel restrictions and the like. Others have talked about strengthening rules to share virus samples and epidemiological data, although I think it’s been better than some of the critics have mentioned, as well as developing schemes and rules for ensuring equitable access to vaccines, treatments, and equipment, as well as working and collaborating together. So I would be interested to know what you think about some of these proposals or any others.

Finally, some critics of—I have to say—of the WHO have even advocated taking pandemic response out of the WHO’s bailiwick and perhaps giving it to another entity, which obviously would be a major shift. But at different times, people have criticized WHO’s capabilities and perhaps resources and authorities for actually directing the sort of full-throated global response, and truly empowered global response you might want to see. So those are, anyway, some things that have been thrown out in the past.

Let me start with Ashish. Are there reform priorities that stand out in your mind when you look at global health governance, particularly for pandemic response?

JHA: Yeah. So I think one of the questions we have to ask ourselves, and this really gets at the heart of WHO, but then leads into your question. Stewart. Is, you know, the struggle of WHO has been a struggle of two competing visions. Is it a member organization or is it the leading public health agency in the world? And 80-90 percent of the times, they’re exactly same thing. But 10-20 percent of the times there is a friction between the two. And pandemics are one of those times, or this one. And I feel like an Ebola as well. There was friction between the two.

And WHO, one of the kind of interesting things that people love to say about it is WHO has legitimacy because it is made up of member states. That’s not untrue. There’s a legitimacy that comes from having governments make up the membership. There is a set of restrictions that come from having member states be your members. And so that legitimacy is a two-sided coin. It really does ultimately hinder WHO’s independence. And what we have decided as a global community, at least in my mind, is largely to favor that kind of government-led legitimacy over freedom and independence. And we’ve seen that play out here.

WHO cannot be independent of China, cannot be independent of the United States. It just can’t, because it’s not only just—and people say it’s funding. It’s not just even funding. It’s just the structure of WHO makes it very, very difficult. And so as long as it made up of member states, and as long as we think that is it’s kind of—its biggest asset, it will do—it will be able to do a good job on many of the things it’s done. The technical stuff, the data gathering, the coordinating of trials. Those things actually become much easier, because of member states. But its ability to call out bad behavior of countries, its ability to sound an alarm before a country is ready to sound the alarm, its ready to call into question evidence and data emerging from a country are all substantially limited. And I can’t come up with what reform you would want to do of WHO that would allow that to happen, short of, like, giving it power over national sovereignty which I just—I’m not sure is a good idea, but more importantly it’s not going to happen.

And so that leaves us with a fundamental question, which is: Do we want an independent agency or not? And if we do, who’s going to fund such a thing, and who’s going to support it, and what’s—how’s it going to come up with its agenda? And I think these are the questions we have to grapple with. What I do believe is once we emerge from this pandemic with, you know, god willing, a vaccine in twelve to eighteen months and this in the rearview mirror, that there is going to have to be some sort of a conversation about either creating a new entity—and, again, I’m not a fan of one more entity in the marketplace—or having something that is independent, because the lack of independence ultimately makes it very difficult for WHO to do some things that we want an entity to do. It allows it to do a whole bunch of other things, and actually I think it does it pretty well, that we want WHO to do.

So that’s a question. I don’t have an answer on how we deal with that, but I think that tension is at the heart of WHO. And all of our frustrations, and all of joys with WHO are really about that central issue. And that’s what we have to deal with.

PATRICK: Ashish, that’s really interesting. It reminds me a little bit of this tension between—you know, is this an independent entity that we can criticize or is in a sense a creature of the member states—reminds me a little bit about a famous line that Richard Holbrooke when he was U.S. envoy to the United Nations was fond of saying, which is that blaming the United Nations for the failure or this or that international fiasco was a big like blaming Madison Square Garden when the Knicks lost, given the power of member states to actually determine their fortunes. But so—and the Knicks lost a lot. Apologize to our New York friends watching this.

But let’s turn things over to Ilona now. Are there reforms that you would prioritize? And I’m also interested if you have any thoughts on how ideally the WHO would be situated or perhaps supported by other multilateral bodies. You know, you mentioned G-7 and G-20, and those types of entities.

KICKBUSCH: Well, Stewart, first of all, you know, I’ve been around for quite some time. And I can’t tell you how many reform suggestions I have been through for WHO. And they appear again and again with, you know, different hats on, and from different organizations. And also, the ones submitted by the United States to the G-7 are things that many of us, including the WHO, including the director-general, have already put forward and have said, you know, this is something we need, something that needs to be different—like, for example, you know, having different levels of a public health emergency of international concern, and all of that.

So, I mean, to some extent I’m really tired of every five years because something happened in the world we start the whole same rigamarole of reform discussions, which doesn’t mean, you know, there can’t be elements of improvement, but—and that is, I think, the key point, and you raised it. If we talk about global health governance, it’s not just those institutions. It is the member states. I’d like to say good global health begins at home. And therefore, if you have international health regulations, and the majority of states do not fill their treaty requirements—and I underline, their treaty requirements—then something is wrong with global health governance.

And that then leads to the point that has been raised, to what extent can WHO actually call out countries who are not fulfilling their treaty requirements? And I think that’s where I’d start. And we do have—you know, and the Australian prime minister drew attention to weapon inspectors. I have drawn attention to the process you have in the human rights world, which is also linked to the U.N. Others have drawn attention to Article 4 of the IMF, saying, you know, if a pandemic element is added to the financial indicators for the ability to get loans from the IMF. So there is a number of models out there that we could use, and a structure we could find, to have that kind of assessment. And I underline, it’s an assessment of treaty obligations. And that is something that people do not talk about.

And then of course still, just to end with that at this point, even if you fulfil your treaty obligations, you still need politicians to take decisions. And the two countries that were ranked best on the global health security index in terms of fulfilling some of these obligations—I think around 70 percent—are the two countries that have not responded well, that is the U.K. and the United States, because the political decisions that were taken were not the ones you needed at that point in time. So I think, you know, let’s be realistic. Let’s reform what could make the most difference. And finally, I think the most important reform is jolly well fund the World Health Organization and make sure that the emergency program is funded only—only—through assessed contributions, so that it’s not dependent on the money from any of the member states that might need to be assessed.

PATRICK: Thank you very much. Those are great comments, and I’m really interested in the notion of, in a sense, an internal review modeled on other global regimes. That’s a fascinating possibility.

David, let’s close with you before we get to questions. So we’ll try to make this quick, I guess. You know, you’ve been at WHO or been in and around WHO quite a long time. Looking—if you look ten years into the future, do you still see it as the center of global health governance, particularly with respect to pandemic response? And if so, what does it need to do or be empowered with to have that position?

HEYMANN: Well, there clearly is a need for some point of reference within the world. I’d just like to give a little comment about a recent experience that I had in a mentorship program for public health leaders, that’s administered through the London School of Hygiene and Tropical Medicine. The person who mentor is in Mongolia. And I was talking with her two weeks ago. And we were talking about COVID, and various different things. And she said to me, she said: You know, we used to be able to look to Europe and North America in order to understand what to do. She said, now we have to look to WHO, because that’s the only group that is really able to advise us at present on what we need to do to be able to deal with this outbreak.

So already people—in developing countries and then across the world—are looking to WHO to be that strong leader. And I think we have to make sure that there is a strong leader. It should be WHO. If it’s not, there has to be a good replacement for that. But you know, in talking about the governance within WHO, and I’ll be brief, I think that the governance, the informal mechanisms that WHO has and the advisory groups that are at a technical level, are very effective and they’re the way things should run. The political tools, such as the treaty that Ilona just talked about, have been developed by countries.

But they’ve been developed many times in a way that makes WHO look weak because they can’t enforce them. And that’s the job of the member states that negotiate these treaties. Certainly, WHO cannot make travel recommendations that countries will not adhere to and look strong. It looks weak because it can’t make those recommendations, and it probably shouldn’t be making those recommendations. So there has to be a whole rethink about what we want from WHO through treaties, through its political governance. And we need to make sure that the technical governance, the technical informal collaborations, continue.

PATRICK: Thank you so much, David. Thanks to all three of you.

We’re now going to open the question and answer session. At this point, I’d like to invite members to join our conversation with their questions. And the operator will remind you how to join the question queue.

BRESNAHAN: (Gives queuing instructions.)

We’ll take our first question from Joseph Nye.

Q: Thank you. This has been very helpful. I have been a basic supporter of WHO and admired its work. People sometimes argue, however, that the regional structure and the devolution to the regions which undercuts the central secretariat is a basic problem, and that in addition to that tension between the secretariat and member nations there is another built-in tension between the director of the overall organization and the power that’s in the regional directorates. Is this a real problem? Is it something can be changed or should be changed?

PATRICK: Thanks Joe. Who would like to take that? And not everyone needs to respond.

Ilona, I see you’re raising your hand.

KICKBUSCH: Yeah. I’m happy to take that. I think Joseph’s question would have been totally correct up to five years ago, were, you know, everyone said, my God, here’s seven WHOs and they never talk to each other, et cetera. Of course there are tensions, just like there are tensions between governors and the president in the United States, et cetera. But definitely a whole number of new kind of consultative structures between headquarters and the regions has been created. There is much greater cooperation than there was in the past, and for the emergency program, and I think that’s really important. For the emergency program, a command and control structure has been introduced. That was one of our key criticisms during the Ebola outbreak in West Africa, that the cooperation between headquarters, the African region of WHO—which at that point was not well-run—and some of the country offices was a catastrophe. And I think that was a real wake-up call.

We can also say that the quality of regional leadership has increased in most of the regions. And so I would say it’s not something that doesn’t happen that there are conflicts, just like in any member state, but it has definitely over the last five years improved significantly and must continue to be improved. And I think that’s something we can say.

PATRICK: Thank you very much, Ilona.

Let’s move to, Operator, the next question, please.

BRESNAHAN: The next question will come from Patricia Rosenfield.

Q: Thank you very much. Can you hear me?

PATRICK: Oh, yes.

Q: Yes. Thank you very much for this wise and informed conversation, which is the best I’ve heard on WHO in a long time. My question is about another set of international actors coming out of civil society. And that’s the role of global philanthropy. I would like to hear from any or all of the speakers about the historic role of global philanthropy, originally the Rockefeller Foundation supported the health arm of the League of Nations, and then built medical capacity and systems capacity, as well as international health arrangements around the world for decades. There are now foundations in every country of the world that are private grant-making—practically every country—private grant-making foundations. So what about bringing to bear the power of global philanthropy to—even to address some of the global—the geopolitical problems, but certainly to build not just the scientific, but the health—public health and systems capacity in developing countries and strengthen WHO’s international health arrangements, especially with developing countries. And special greetings to Ilona, after a very long time.


PATRICK: Thank you. Ashish, or David, or Ilona, would somebody like to respond to that?

HEYMANN: Well, I’ll say—go ahead, Ashish. No, go ahead.

JHA: All right.

HEYMANN: Let me just say that—(laughs)—go ahead.

JHA: All right. I will start. I was going to talk a little bit about the Gates Foundation, just because as a private philanthropy it is the eight-hundred-pound gorilla in the room, certainly has become in global health. You know, their strategy—so I’m talking very much about, obviously, the present day and not the historical context. But their strategy very much has been not to get into health systems development, to not be a major donor of helping countries build up their own systems, but instead work on very specific and targeted issues, such as obviously polio, to develop innovative new solutions, fund vaccines. And I get why they do that and, ultimately, why it is that they feel like that is a better strategy for their—for their dollars.

What’s been really interesting in watching this pandemic is almost all of their investments are at substantial risk because all of the progress that they have made is going to get undone by a variety of ways in which this—(audio break)—I don’t think philanthropy can ultimately—(audio break).

Oops. OK. I don’t think it can—can you still hear me? I got—

PATRICK: Yeah. We lost you for just a second, but you were saying that you understood why the Gates Foundation was doing this, but many of the good things would be undone by the COVID pandemic.

JHA: Hello? Can you hear me?

PATRICK: Yes, we can hear you. Can you hear us?

JHA: I can’t hear you. All right. (Laughs.) I’m going to just keep talking and hope that you can hear me. (Laughs.) Sorry. Technical issues. So I think philanthropy does have to do some rethinking about their own role in pandemic preparedness. I don’t see philanthropy filling in, in a way they might have been able to do fifty or a hundred years ago. There’s still going to have to be a very substantial role for governments. But it has been interesting watching Gates response in the context of this outbreak, that their investments really are at risk given that they have not invested in health systems and these issues. Let me stop there.

PATRICK: Super. That’s great, Ashish. Let’s turn to David. You were going to make a comment.

HEYMANN: Yeah, no. I would just say that, very much similar to what Ashish has said, the Rockefeller Foundation, when they began to be interested in health, gave us the yellow fever vaccine. Then the Gates Foundation, when there was a need for a monovalent polio vaccine, gave us a monovalent polio vaccine. When there was a need for a meningitis vaccine for sub-Saharan Africa, they were able to give us that vaccine, to transfer the technology to India to produce it. So these foundations are extremely important. The risk is that they do buy—that they don’t buy into the priorities, but that they have their own priorities. But I haven’t seen that happen to a great extent. I think that they are very responsive to the needs of what the organizations, such as WHO, have. So I’m very positive about the input in specific areas that the foundations are having.

PATRICK: Yeah. Ilona, and then we’ll go to—

KICKBUSCH: Yeah. I would like to go back to history because the Rockefeller Foundation did something extraordinary. It built public health institutes. It built institutes that trained public health experts. And those institutes still exist. They built something that was so incredibly sustainable. And people, for example, who have trained at Rockefeller built and financed public health institutes became some of the founders of the WHO. So you know, I think there is something that foundations could do that is really sustainable.

And if you look at the pandemic preparedness issues now, the issue around, you know, building, strengthening, for example, the African CDC, building CDCs throughout the African region, modeled perhaps on the Nigerian CDC, et cetera. I mean, just imagine the sustainability and the long-term impact of building such institutions, of all the people that will be trained in those institutions, is just extraordinary. And therefore, I would say I do wish—and I’ve often said it to them. I do wish the Gates Foundation had learned a little bit more from the Rockefeller Foundation in terms of building these sustainable institutions that make such an extraordinary difference.

PATRICK: Thank you.

Operator, next question, please.

BRESNAHAN: We’ll take the next question from Lara Jakes.

Q: Hello?

PATRICK: Yes, Lara, we can—Lara, we can hear you.

Q: Great, thanks. Sorry about that. Thanks for doing this. Ilona mentioned that member states in Europe miss and want the United States’ participation. I’m just wondering what the United States risks, either in health or diplomacy, losing by cutting funds or alternatively withdrawing, as has been suggested in recent days. There have been several State Department briefings suggesting that State is looking instead to work with alternate organizations. I don’t even know what they would be. If you do, I’d be interested to hear what the alternatives are. Thanks.

PATRICK: Any of our panelists interested in—yes. Ashish.

JHA: OK. I’m hoping with technical issues resolved.

So I have seen this as a lot of bluster, without necessarily a whole lot of carry through. I am—look, I think the bottom line is here the president is in big trouble. The political numbers looked bad for him. The response to the outbreak is going very, very badly. And he needs scapegoats. And so I see a lot of kind of bluster of we’re going to cut off our funding, and we’ll only do exceptions, and we want an alternative institution. But I don’t actually think much of that is going to happen. I can imagine short-term reductions in financial support. But I don’t think that there is any real appetite in the U.S. government to walk away from WHO for the long run. This is much more political posturing. So the part of me just sort of says, we should take the president, and this bluster, a little less seriously. It’s not—I suspect it will not end up leading to a whole lot of action for the long run.

PATRICK: Great. Let’s go ahead to the next question if we can get that. Thanks.

BRESNAHAN: We’ll take the next question from Abby Cohen.

Q: Hi. I’d like to add my thanks to the others who’ve expressed appreciation for this terrific conversation. I’d like to go back to a point that Ilona made early on about the financing for the WHO. You know, so much of it is coming from voluntary contributions, and it’s not just the fact that the Gates Foundation is the second-largest contributor, and GAVI, which in turn is getting is money from Gates, is the fourth-largest contributor. But when you look at individual nations, the lion’s share of what they are giving is really voluntary rather than assessed. I would add, parenthetically, that the main exception to that is China. They’re not a big contributor, I think something like number fifteen, but almost all of that is assessed contribution. So, Ilona and others, if you could go back to this and talk about what a sustainable model might be for financing the WHO, I think that would be extremely helpful, including your interesting comments about the role that philanthropy should be taking in this, and whether it should be determining the priorities to such a large extent.

PATRICK: Ilona, would you like to take this?

KICKBUSCH: Well, I’m happy to start and, you know, let the others come in. I think many of us are calling for increased assessed—are calling for increased assessed contributions to the WHO. And going back to an earlier model, which was around sixty-forty. Some listeners might know that Germany took an initiative a couple of years ago to increased assessed contributions by 10 percent. They were able to get 3 percent, which is a drop on a hot stone, as we say in German. The important thing is really to have member states, and maybe this crisis can help us with this, to actually really revisit it—revisit this funding. And it will also have to be revisited because it creates additional problems.

It’s not just, as you indicated, you know, there are philanthropies that start to influence priorities in one way or the other, even though the budget process has been changed to sort of try and keep that at bay a bit. But it’s also that usually the assessed contributions are paid from one part of government, ministries of health or foreign affairs, et cetera, whereas the voluntary contributions are paid, if we’re talking about countries, are paid through development agencies and ministries of development, who have other priorities and whose priorities are not usually about systems building but, again, very disease-focused.

So you get a very complex mixture. Of course, the reason we’re in that situation goes back to the 1980s and, dare I say it, to the United States and President Reagan, who also threatened to leave the WHO if the budget process was not changed, and if there were not, what you call it, a thing you put on assessed contributions so that the budget would no longer grow. At the same time, all—a cap, yeah. All countries then asked for WHO do to more, and more, and more, including this new big operational program for health emergencies. So I come back to my earlier point: We need more assessed contributions. We need to definitely agree that the emergency program be paid through assessed contributions only and be assured that it’s paid.

At present it’s at 80 percent, so countries are not putting their money where their mouth is. And therefore, I think that budget discussion is going to be central. Actually, Kishwama Rubani (ph), who, you know, also writes about the WHO actually suggested that if China wanted to move into global health, this is the area they should take up, to increase WHO assessed contributions by 50 percent.

PATRICK: To pick up on those great points, you know, this pattern on the part of the United States of preferring to have voluntary versus assessed contributions, as you say, goes back quite a bit. It’s particularly popular on the conservative side of the House, as you know, politically, because it allowed the United States to, in a sense, pick and choose and, in the view of some, avoid subsidizing dysfunctionality in international organizations, as it’s often described. So it also has the benefits from a legal perspective of not being, in a sense, treaty binding because they are, in a sense, voluntary contributions. But it’s not, as you had mentioned, not just WHO that has experienced this sort of a political dynamic within the United States.

KICKBUSCH: Yeah. UNESCO is good example.

PATRICK: Indeed. Indeed.

I think, unless David or Ashish has comments, we might move onto the next question. Yes, let’s get that.

BRESNAHAN: We’ll take the next question from Pien Huang.

Q: Can you hear me? Hello, can you hear me?

PATRICK: We can hear you now.

Q: OK. Thanks. Sorry about that.

So I have noticed from watching a lot of WHO press conferences that they have recently shifted their tone to a defensive stance. You know, in every press conference they’re giving a day-by-day retread of what happens between December 31 and January 30. And they take direct digs at Taiwan and, you know, more veiled ones at the U.S. president. So I was wondering, from your perspective, is this a useful strategy? And is it—is it serving to help the WHO establish its—reestablish its leadership in the world?

HEYMANN: You know, I think WHO does best if it sticks to technical messages, although WHO is a political organization at the top, and it does have political overtones. But my experience at WHO has been that the credibility is when there’s a solid, evidence-based recommendation for best practices promoted. And I think WHO does best in sticking to that, and in helping the media and the general populations understand the issues, rather than going into technical—or, political issues that may in the end not be a worthwhile battle. So, again, my feeling is the WHO should use its technical arms more and its political arms less.

PATRICK: I think I’m seeing some nodding. I think that that meets with some broad agreement. Next question, please.

BRESNAHAN: We’ll take the next question from Leonard Rubenstein.

Q: Thank you. This is a great discussion. I’d like to return to the—I’m Leonard Rubenstein from Johns Hopkins.

I’d like to return to the tension between independence and control by member states. There are U.N. agencies, especially the human rights agencies and even UNICEF, which have navigated this tension fairly well, under the circumstances. Some high commissioners of human rights have lost their jobs, but by and large they do speak out against member states when they believe the situation requires. Do you think that they could be any kind of model or precedent for gaining a better balance between member state control and independence at WHO?

HEYMANN: You know, maybe I’ll say just a word. The WHO has been, also, outspoken depending on their directors general that have been present. Gro Harlem Brundtland was, as you know, a former prime minister and a pediatrician, and when China was not sharing information about the outbreak of SARS coronavirus she accused them publicly of putting the rest of the world at risk. And that unblocked a whole situation that involved the vice premier coming to Geneva to meet with Brundtland, and the system opened up in China, and it’s what’s developed into a very serious public-health institute—this China CDC—throughout the country, and reporting in a technical manner what’s going on in the country.

And I can say that I’ve been listening to the China CDC provide their information. They provide the information when it’s asked, and if they don’t have the answer they go and get it for us. So I think that there have been that confrontational approach at WHO, but it takes a very strong leader who’s a leader and can bring member countries along with themselves, rather than being out there on their own.

KICKBUSCH: Even though, if I might say, it was easier for Gro Harlem Brundtland aside, you know, from her personality and experience, to do what she did because the revision of the IHR had not yet been done. Because, actually, the IHR and the rules it sets ties the director general’s hands much more in calling out countries than was the case before, when we didn’t have a treaty. And therefore, I think one has to be very clear about that, that a DG now actually has less freedom to call countries out because of the IHR than was the case when the IHR did not exist. So, you know, there you can see the tension and the pros and cons of having a set of rules or being able to, in quotes, “do as you wish” and speak out as a strong leader. And I think the balancing act that somebody like Tedros has to do right now in an extreme geopolitical situation and the rules—that frame that the—that the IHR gives him—is really a difficult balancing act.

I must also say in watching I did not see what the press conferences are doing as defensive. I think, you know, after three months of being through the pandemic, WHO has laid out very clearly the timelines of what happened when. And you know, if you take those timelines and you take the United States timeline, as was shown in the New York Times recently, I mean, that tells its own story. And so, you know, WHO has to do nothing else right now—and I don’t think that’s defensive—as to say, you know, we followed the rules, we followed our rulebook, and this is what you did. And if you want us to do something else, it is you, the member states, who have to change the rules, and we’ll follow.

PATRICK: Thank you.

Ashish, did you have a comment?

JHA: Yeah, just a quick—two quick things. I think—well, let me just make one, which is, you know, institutions that rely on or need an extraordinarily capable leader in order to be effective are not institutions that are designed well because we can’t expect a Gro as DG at every moment. We could think about that kind of a political leader when we choose somebody, but Dr. Tedros—who I actually have been very supportive of; I think he’s done a good job—you know, was a foreign minister and a health minister, and has a lot of political experience. And ultimately, it’s very, very hard, given the constraints at WHO, for any leader to stand up to member states in a way that Gro did.

And so part of me always worries when we look for kind of the individual hero as the solution. The question is, what’s the systematic solution so that an average DG can do a very good job at what needs to be done? Because that’s much more sustainable than let’s pray for a really terrific one. Again, and this is no criticism of Dr. Tedros, but I’m just saying Gro Brundtland was really so singular in her ability to do these things that I’m not sure we can rely on her or future people like her.

PATRICK: Thank you.

KICKBUSCH: Yeah. We can also not be sure that the member states like such a leader because Gro was only there for one term, as you know.

JHA: Exactly. That’s the cost. That’s the cost. (Laughter.)

PATRICK: Operator, do we have time for one more question, or is it time to wrap it up?

BRESNAHAN: We can take one more. The next one will come from Annabelle Timsit.

Q: Hi. Can you all hear me?


Q: You can, OK. Well, thank you so much for a very informative conversation. And I have spoken to a few of you for stories in the past, so I really appreciate you taking the time.

My question is for Ilona. I’m curious, as the WHO is getting ready for the upcoming World Health Assembly, and there’s been some reporting from Reuters that says that Australia is planning on putting forward its proposal for an independent review at the World Health Assembly, I’m wondering if you could tell us a little bit about how the preparations for that are going and how the WHO may be preparing for such an effort.

KICKBUSCH: Yes, I could say one or two things, and that is that—and actually, I was speaking to some of the diplomatic colleagues in Geneva today. So at present there is an approach developing in Geneva that is, first of all, saying that at this point in the pandemic we do not want to sideline resources into independent reviews of any kind, point one.

Point two, we need to be very clear about using the review mechanisms the organization already has to the fullest extent, and David already alluded to some of them.

And point three, there is, you know, absolutely no feeling that if countries feel at a certain point in time that those three—four review mechanisms that already exist are not sufficient, then one can definitely look into—but later on, you know, when we’re further, hopefully after the pandemic—we can look into something that’s perhaps a little bit more like the interim assessment that was done after Ebola. I was part of that team, and it led actually to the establishment of the program we have now and was able to work totally independently.

So I think we’re starting to see a consensus emerge in Geneva that, you know, there is no breaking over the knee of, you know, let’s quickly assess something. But you have to think of a very systematic process in which member states would also be very fully involved, just like they were after the Ebola assessment, and I think that’s important. And if I say member states, I mean a consensus of all member states. It’s 194 member states of that organization, and we frequently forget that. We tend to talk only about a few. And there are many who want and need a strong WHO, particularly in Africa, in this very dire situation, and they want the organization to be able to work rather than be tied up in all kinds of hearings around assessment.

PATRICK: Thank you very much, Ilona.

I think that we, alas, as often happens, have, right when we’re getting to a(n) even more rich discussion, getting to the end of our time. And we try to—try to begin and end on time here at the Council on Foreign Relations, even when we’re operating remotely. I want to thank everyone for joining the virtual meeting. And I can’t thank Ilona, David, and Ashish enough. I learned a tremendous amount from your wisdom and your experience, and I hope to see you again perhaps in more proximate terms—(laughs)—and we can have a chat, an informal chat.

Thank everyone for joining the meeting. Please note, as I said, the audio and video are going to be posted on the CFR website. For all of you members and other guests who have been watching, we hope that you can join us for our next virtual meeting, which will take place on Tuesday, May 5, from 3 until 4 p.m. Eastern time, and that will focus on Asia’s response to the coronavirus. May you all continue to persist in good health and good cheer. Look forward to seeing you all.


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