For weeks, the World Health Organization resisted declaring the coronavirus outbreak a pandemic, fearing that doing so would incite panic across the globe.
But facing the cameras on Wednesday, the agency’s director general, Dr. Tedros Adhanom Ghebreyesus, did just that, asking for global unity to “change the course of this pandemic.”
It was a symbolic moment that underscored the standing of the WHO as the world’s leading public health agency. But it also reflected the WHO’s underlying weakness as an organization that by international treaty is supposed to lead and coordinate the global fight against the coronavirus — yet that has, in many ways, been marginalized.
Global solidarity has been noticeably absent in the fight to stop an outbreak that has already killed more than 4,300 people and spread to more than 110 countries. No one seems to be in charge. There doesn’t seem to be a plan.
Except there is one. The problem is that relatively few countries are paying much attention to it.
Fifteen years ago, the WHO undertook a major revision of the International Health Regulations, the global framework for responding to outbreaks. The revision was intended to correct flaws in the global response to the 2003 SARS outbreak, which killed hundreds of people and pushed advanced health care systems to the breaking point.
The basic idea was that the WHO would serve as a central coordinating body. Countries would notify the agency about outbreaks and share information to help scientists address an epidemic at the global level. The WHO would coordinate efforts on containment, declare emergencies and make recommendations. The revised regulation is legally binding and has been signed by 196 countries, including the United States.
But dozens of countries are flouting the international regulations and snubbing their obligations. Some have failed to report outbreaks to the organization, as required. Others have instituted international travel restrictions, against the advice of the WHO and without notifying global health officials.
“One of the biggest challenges we face is that too many affected countries are still not sharing data with WHO,” Tedros said last month. He has also blamed some countries — he has refused to specify which ones — for failing to take the outbreak seriously enough.
As part of the United Nations, the WHO is broadly influential yet hampered by budget and political pressures. It lacks meaningful enforcement authority, creating a telling power imbalance. It is often accused of kowtowing to its donors — from powerful players like the United States and China to private funders like the Gates Foundation.
These contradictions contributed to the agency’s much-criticized response to the Ebola outbreak in West Africa and led some scholars to question the need for such a weak institution. But Rebecca Katz, a scholar at Georgetown University, said such criticism misses a fundamental point.
“If there wasn’t a WHO, you’d have to invent it,” said Katz, who has studied health regulations for more than a decade. “They are in a bit of a tough spot because you know you have international law but then you also know that every nation is sovereign,” she said.
This time, some former critics credit the WHO for doing a better job, declaring a global emergency much quicker than it did during the SARS and Ebola outbreaks, consistently sharing information with the public and convening more than 300 scientists and research funders to help develop tests, vaccines and medicines.
Even so, the agency is also marginalized in many ways.
The most obvious examples are the global flouting of international travel restrictions. More than 70 countries have instituted the restrictions, according to the WHO including the United States, where President Donald Trump announced on Wednesday night restrictions to travel from the European continent.
Yet in four advisories it has issued since early January, the WHO has consistently advised against them, cautioning that limits on international movement during public health emergencies are unlikely to stop the pathogen’s spread.
The rules do not apply to domestic travel restrictions or to decisions made by private airlines, but the WHO has repeatedly warned that international bans can block needed resources or delay aid and technical support. Such restrictions are only justified at the beginning of an outbreak to buy nations time to prepare, the agency said. Beyond that, they are more likely to cause significant economic and social harm.
Meanwhile, only 45 of the more than 70 countries who have adopted international travel restrictions have fulfilled the requirement to report their actions to the agency, a spokesman said.
Restricting travel “is a good political placebo. It’s going to make people feel safe,” said Clare Wenham at the London School of Economics, a scholar who has studied the health regulations for more than a decade. “Why are we not learning that this doesn’t work?” Wenham asked about travel restrictions.
WHO itself has sent out mixed signals in recent weeks. In a report it issued this week, the agency said that some travel restrictions “may have delayed the importation of new cases.” But WHO did not change its fundamental opposition to international restrictions or revise its travel advisory.
Then there is the unwillingness of some countries to lift a ban on the export of protective equipment, complicating the broader fight against the disease. France and Germany have put limits on exports of such gear.
“We can understand that governments have a primary responsibility to their own health workers,” said Dr. Michael Ryan, who heads the WHO’s health emergencies program.
He urged nations to stop hoarding gear and called for solidarity across the globe.
“The life of a health worker in one country is certainly as valued as the life of a health worker in another,” Ryan said Monday.
The national governments who signed onto the international regulation also left themselves a loophole, which they are exploiting now.
The loophole was the product of hours of negotiations in Geneva, where the revisions were finalized in 2005, according to Gian Luca Burci, who served as the agency’s legal counsel for 11 years. Burci said negotiators stayed up until 5 a.m. before agreeing on a trade-off that balanced “public health considerations and the retention of the ultimate political power.”
Countries were reluctant to cede total control to an international agency. They drafted a provision that gave them the right to take health measures that they believed would have similar or better results than WHO recommendations — on the premise that these measures were scientifically grounded and for the common good.
“States gave themselves a ‘get-out-of-jail-free’ card,” Burci said.
Under the rules, countries are obligated to report to the health agency within 48 hours any measures that they take beyond the collective guidelines as well as report the rationale behind their actions. Many countries have failed to do so during the coronavirus outbreak, and the WHO can do little about it.
In some cases, WHO officials only learned of travel shutdowns after they happened, from reports in the media.
“What do we really mean if nobody is following WHO’s recommendation with impunity,” Burci asked.
Because they have no power to enforce international regulations, WHO officials have to walk a diplomatic tightrope. In a statement, a WHO spokesman said that the agency “cannot compel countries to change measures they have implemented.”
Last month, Tedros sent two letters, which have not been made public, reminding nations about their obligations. His staff has collated media reports on the flurry of travel restrictions and is chasing after countries to obtain their rationale.
Agency officials have resisted naming and shaming countries that breach the rules and have largely dodged media questions on the subject.
“The WHO doesn’t interact in public debate or criticize our member states in public,” Ryan said Wednesday when asked which countries had failed to rise to the occasion.
“You know who you are,” Ryan said.
Part of that hesitation comes down to money, said Dr. Ashish Jha, a director of Harvard Global Health Institute. The organization has said that it needs $675 million to fund its response to the coronavirus outbreaks. As of this week, nations have pledged to donate about $300 million.
“WHO is at the mercy of its member states,” Jha said. “Countries don’t have to listen.”
Even as the agency struggles to nudge member states to comply with the regulations, the coronavirus pandemic poses major questions for the future. One pressing question is on how the world will cope if an outbreak develops in countries with underdeveloped health care systems.
Two-thirds of the world’s countries lack the necessary laboratories and surveillance systems to detect outbreaks and comply with international regulations. The Group of 7 has pledged to help poorer nations but have not always followed through.
The world is not ready for “a fast-moving, virulent respiratory pathogen pandemic,” a WHO report said last year.
Katz, the Georgetown scholar, said stronger international regulations would help prepare for such an outbreak.
“This is what we have. This is the agreement we have. This is the organization we have,” she said.
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