The World Health Organisation and the politics of health internationalism

This artcle was originally published as part of the ”Viral Condition” virtual forum edited by Ravinder Kaur for the academic journal Identities. Global Studies in Culture and Power. Author: Steven L. B. Jensen, senior researcher at the Danish Institute for Human Rights

At the 1979 World Health Assembly, the then Director-General of the World Health Organisation Halfdan Mahler was in a contemplative mood when delivering his opening speech. In front of the UN member states, he stated: “Plato said some 2000 years ago: ‘What is honoured in a country is cultivated there’. Do we today honour world health or do we not?”

Mahler gave this speech the same year that WHO declared smallpox eradicated globally – still one of the greatest successes in the organisation’s history. This was, however, no reason for WHO or the international community to rest on any laurels. It was an opportunity. What smallpox eradication meant - in Mahler’s mind - was that funds were now freed up for the international community to address a whole range of other diseases and massive health problems around the world.

In moving forward with this, Mahler was concerned about the relationship between philosophy and action – about having the right health doctrines and putting them into practice. This concern is as relevant now as then as the world grapples with a relentless pandemic. The recent debates on “universal health coverage” echo the cherished goal of “Health for All” that the WHO secured international agreement on – under Mahler’s leadership - as a major policy goal with the 1978 Alma Ata Declaration. The case for universality will no doubt feature with renewed urgency when the COVID-19 response moves from an emergency to a more longer-term health action.

At the heart of the debate lay concerns about the question of responsibility. Mahler believed that developed countries had a double responsibility “to their own people and to the peoples of the developing countries struggling to extricate themselves from historical injustice and from the vicious circle of poverty and disease – there is a very close relationship between what a country does within its own boundaries and what it is able to do for other countries.” What he was talking about could be labelled as “the responsibilities of internationalism”.

What would be our response to this challenge in 2020? Four decades on, it seems highly relevant to pose Mahler’s opening question today as the health, social, economic and security impacts of the COVID-19 pandemic is felt worldwide. The question that needs to be asked is: What types of politics and policies have we been honouring and cultivating in recent times?

The COVID-19 pandemic is a global moment of truth for the state – quite literally – we are (citizens) in. We see clearly now when what has been “honoured” by political leaders has not been health, social protections or human rights but authoritarianism, austerity politics, corruption and a tolerance for widespread inequalities. Societal fractures are exacerbated and exposed. The cost is lethal.

It has become clear that low paid and marginalized workers forced into precarious work are in reality the providers of essential services. They keep societies functioning. At the same time, they are at a much higher risk of exposure of contracting the coronavirus while more well-off citizens move into isolation. If we are in a war against the coronavirus – as has frequently been stated – these workers were the ones that mobilised while they rest of us demobilized. The pandemic response in many countries has truly been the Charge of the Lightly Paid Brigade. COVID-19 is very much a story of inequalities.

We also see clearly the beneficial results where states have tried to protect welfare provisions, human rights, social standards, public trust and transparency in public policy-making as part of the political culture. The quality of political leadership and community engagement are defining factors for the epidemiological and socio-economic outcomes citizens will face. Previous investments in public health are paying off during this emergency. As the medical journal, The Lancet wrote on 20 March, "Presently, health-care workers are every country's most valuable resource".

The COVID-19 pandemic is simultaneously a moment of truth for the state of internationalism in today’s world. There is much need for the WHO to fulfil leadership, scientific, coordinating and advisory roles and to provide technical support to countries. The challenge is that these international roles are conducted in a world of state sovereignty where the sense of the “responsibilities of internationalism” is viewed very unevenly (to put it mildly). This is a reality and a paradox that has always defined the work of the United Nations.

Internationalism was a project of nations that were willing to cooperate. We seem to be living in a particularly volatile era with great uncertainty surrounding the state of the internationalism we desperately need. In Mahler’s words, internationalism is the right philosophy to guide our actions but that still offers no guarantees that it will be put into practice. As we consider the inadequacies of the WHO, we need to turn the spotlight on the behaviours of the member states too. That is especially the case when a number of states or at least their political leaders see a deliberate interest in destroying multilateralism and international organisations.

Internationalism is wrapped in state sovereignty in all sorts of visible and invisible ways. The work of the World Health Organisation is no exception. The risk of being caught in political crossfires is ever present. The complexity of this spills into how an agency navigates the tempestuous waters of global politics between Scylla and Charybdis in a world with many one-eyed Cyclops.

Diplomacy is therefore a requirement. In multilateral diplomacy one is forced to navigate manifold state interests, personal and political vanities by both high-level and lower-level actors, internal bureaucracies with managerial and funding challenges, the ritualized procedures of multilateral governance as well as undertake the hard work of consensus-building to progress with international policy-making and norm-setting. It is therefore a system where not only substance is substance. Procedure is also substance. It can at times feel like there are more than 190 masters to serve – although some clearly more dominant than others.

The politics of the blame-game is rooted in this tug-of-war. This has become full-blown with the COVID-19 pandemic to debilitating effect in key international forums such as the G7 and the UN Security Council. The blame game is a well-known phenomenon in the field of global health. The old story of the “French disease”, the “Spanish disease” or the “Italian disease” of syphilis provides one illustration hereof.

In his 2007 book “The AIDS Pandemic: The collision of epidemiology with political correctness”, the former WHO epidemiologist James Chin narrates a story of a presentation that he gave in the late 1980s at an HIV/AIDS briefing to World Health Assembly delegates. Chin announced at the beginning of his talk that WHO had determined the specific origin of HIV/AIDS and that there was near-universal agreement about this among the experts he had consulted. He would reveal their conclusion at the end of his presentation.

There was visible discomfort in the room – even with his WHO boss. At the end, Chin revealed that the clear consensus was that “HIV/AIDS originated in someone else’s country.” There was a sigh of relief in the room after this.

The blame game emerges when scapegoating and national prejudices come to the forefront or when powerful self-interest defines political actions. It is a way of diverting responsibility for one’s own failings. Internationalism or multilateralism becomes collateral damage. The Trump Administration has for example insisted that references to the Chinese origins of the virus (e.g. “Wuhan virus”) had to be included in communiqués or resolution texts from the G7 and the UN Security Council. This has met with resistance -because the motives for this have been abundantly clear. The consequence has been that no major action has been taken by these international forums (the UN Security Council did eventually have a session on COVID-19 on 9 April, but we still await to see any action emerging from the Council). This counter-productive approach can then be used to accuse the United Nations of failure in a way that obscures that the failure is with states – not with the UN agencies themselves.

The fact is that the blame game politics also frequently targets international organisations or internationalism itself. It is one of the ways that member states conveniently make use of the United Nations. This has happened in recent weeks. WHO has been in the firing line. On April 7, at a White House press conference, President Trump placed blame on WHO for not calling the warnings on the virus early enough and correctly and more than implying that WHO was too close to the Chinese government. President Trump threatened to put “a powerful hold” on funding to the WHO.

The response by the WHO’s Executive Director Tedros Adhanom Ghebreyesus to President Trump’s attacks came immediately at the agency’s daily press briefing on 8 April. His response represented classic UN internationalism.

After a powerful factual introductory statement that clarified the chronology of the 100 days since WHO on 31 December 2019 had been notified of the first cases of “pneumonia with unknown cause in China” and all the actions they had taken, he called for “honest solidarity at the global level” and “honest leadership from the US and China” and continued “Let us unite.

Unity is the only option to defeat this virus. Lack of unity – please prepare for the worst.” This was reasonable and in many ways standard rhetoric from a high-level leader at the United Nations.

However, when Dr. Tedros argued that “we don’t do politics in the WHO” and called for “quarantining COVID-19 politics” for the sake of unity, he was entering more questionable territory. These statements may be useful as soundbites and they are sentiments for which you can have some sympathy.

However, they are at the same time wilfully naïve or a form of denial. One thing that the new viral condition has made evidently clear is that internationalism and the quest for unity – e.g. when facing a global humanitarian crisis - are a form of politics. It is the politics of the UN Charter and having the UN as a global diplomatic forum for dispute-resolution and coordinated action over 75 years. This is not neutral as internationalism is a political choice. Internationalism is national politics by other means.

It is impossible to deny this as a political reality in a world with authoritarian nationalism, scapegoating and targeting of vulnerable populations that gravitates the response to COVID-19 away from what WHO is trying to do.

Despite the scientific and technical basis for its work, the internationalism that the WHO stands for is a form of politics. In a world with political instrumentalization of fake news at the highest levels of national politics, facts, science and the philosophy of building trust for the common good are in themselves political phenomenon and values. When Dr. Tedros rightfully calls for “humility” and “compassion” as the philosophies to guide our actions, he is not just espousing his personal values. He is also making political claims about the “responsibilities of internationalism.”

The advantage of recognizing this internationalism as a form of politics is that we then know it is not stable or a thing of permanence that we can take for granted. It is something that we have to mobilize around, organize for and fight to sustain and advance because that is what one does in politics.

The political stakes for this were raised on 14 April when President Trump announced his decision to withhold funding to the World Health Organisation in the midst of a pandemic where the chronically under-resourced WHO is trying to coordinate a global response. This is a dramatic move – even if it was less surprising given the previous week’s announcement from his side. It is a deliberate targeting of internationalism to cover up President Trump’s own failings.

However, this time the collateral damage will not merely have a negative impact on UN structures. It will cause significant damage in what is at the heart of internationalism – namely advancing coordinated action at the national level to improve the plight of people all around the world. Laurie Garrett, one of the most important analysts of global health in the last three decades, Pulitzer Prize winning journalist and expert from the Council on Foreign Relations, has concisely laid out the consequences of his decision:

"This is damnable. A spiteful Trump act carried out in an endless White House blame game. Meanwhile, WHO is the only lifeline most African, Latin American and Asia Pacific nations have. This Trump action will cost lives -- possibly 100s of 1000s of them. Reprehensible."

We should of course remember to be scathing of the Chinese dictatorial regime’s failures in bringing timely messages to the world about the corona outbreak e.g. by suppressing the voices of Chinese medical doctors that raised alarm about the nature of the coronavirus based on their own experiences from treating patients. Freedom of expression and exchange of information are international legal standards that sustain internationalism. States that violate these fail their citizens and the international community.

The attacks on internationalism by both China and the US point to an important conclusion about the state of the world that we urgently need to understand. Internationalism needs its own constituencies. We need to demand from our national politicians that they support it, act in accordance with its values and hold them accountable for it. The alternative is the politics of division, nationalism and populism which we have seen being “cultivated” in many countries in recent years and have become sources of conflicts. The new viral condition will now show the escalating cost of that approach. Last week, the WHO Executive Director Dr. Tedros described this alternative as the politics of the “many more body-bags” because it will come at a prize. Still, the internationalism he espouses is fiercely contested and actively undermined.

Meanwhile, the question his predecessor as WHO Executive Director asked the UN member states back in 1979 has moved centre stage in global politics. “Do we today honour world health or do we not?” The pandemic jury is out. We had better prepare our responses because the answers will define the politics of our age. So, I am asking for a friend (called Plato): What exactly is it that we want to “honour” and “cultivate” in the COVID-19 era?