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The World Health Organisation and Pandemic Politics: A reply to David Fidler

I’m not a big fan of David Fidler’s global health writing. Sometimes I wonder why. He was quite prolific a few years ago; less so nowadays. But given that he’s well-known, has written a lot and most people I know think he’s great, self-doubt creeps in from time to time. So sometimes, when he writes something new, I give his work another go, just to make sure.

He wrote an article recently for Think Global Health entitled The World Health Organisation and Pandemic Politics and, inevitably, I found myself reading it. I’m not going to critique the entire article, just the first paragraph. Because, to be honest, that’s really all you need to read. Let me break the paragraph down for you, sentence by sentence.

Sentence number 1

“From the start, the World Health Organization (WHO) has been at the center of the COVID-19 storm—and the target of criticism”.

This sounds significant, but it isn’t. The pandemic is what we call in the trade a ‘wicked problem’ and, as such, has no start or end. There wasn’t a storm circulating WHO ‘from the start’, but there is one now because global health pundits like Fidler are helping to whip one up. Oh, and, as if you need any reminding, anyone and everyone with any degree of influence will always be the target of criticism. So telling us that WHO is “the target of criticism” is like telling us that the sky is blue, or white, or grey, or whatever colour the sky is – it’s rarely blue. It’s not blue at night, is it.

The sentence is, in other words, complete fiction. Furthermore, seeing as we’re making shit up, the article could start in any number of ways. For example, why not say this instead: “From the start, the World Health Organisation (WHO) has been leading the international COVID-19 response with consistent public health advice and guidance – and received widespread support from its member states”. Why not say that?

Fidler, like all of us, is selective in his choice of facts, data and information, is biased, has an ideological perspective, interests and concerns. Crucially, therefore, this opening sentence has nothing to do with him being an expert. It is simply an observation and, as such, as valid as anyone else’s. But it won’t be seen that way. Fidler is a professor, a lawyer, an expert even. And professors, lawyers and experts don’t make stuff up.

Sentence number 2

“The pandemic and the controversies associated with it have created an immediate crisis for WHO as COVID-19 rages on”.

Here’s the thing. It never even occurred to me that WHO was facing “an immediate crisis” until I read Fidler’s article. I’ve been writing and teaching about the politics of global and international health for years, and – just like you – I’ve been following this pandemic reasonably closely. I know about the challenges, both internal and external, that WHO has been struggling with over the years. The Organisation has always been in some form of crisis, mainly because it doesn’t have any fucking money! But, honestly, mostly what I see in response to this pandemic is the incredible work it is doing with almost no resources. What I see is a leader at its helm who – and this is such a rare quality in high politics – has humility and compassion. Someone who actually appears to give a fuck about the majority of the Organisation’s member states who are all-but invisible in the writings of Western, white, liberal analysis.

So again, I invite you to think about how you might re-write Fidler’s second sentence. How about writing it like this instead: “The pandemic and the controversies associated with it have created an opportunity for WHO to demonstrate its leadership and encourage member states to fully support the Organisation’s response to the pandemic”. I hope you’re beginning to see a theme emerging here?

Sentence number 3

“But it’s also created a prospective crisis because the outbreak and political reactions to it will shape the future of WHO”.

Unless Fidler is psychic, there is no basis from which he might divine a “prospective crisis”. Furthermore, the sentence seems to proceed logically, with the first and second clauses supporting one another. But look again and you’ll see that the sentence makes very little sense. The word “because’ suggests cause and effect, but really it’s just gobbledy-gook. I mean, you can kind of guess what he’s trying to say but…actually, you can’t. David tells us that: “the outbreak and political reactions to it will shape the future of WHO”. Yes, OF COURSE THEY WILL. How could they not? But maybe ‘the shape’ will be something positive and NOT A FUCKING CRISIS! WHO could just possibly come out of all of this stronger. I hope so. 

Can you see, now, why I find Fidler’s writing really irritating? All of his stuff is like this. I remember working at Sussex University many years ago. My job for about a month was, believe it or not, to read David Fidler’s articles. Just that. I sat down at 9.30 in the morning and until about 5.00 in the evening I just read his articles. I broke down his arguments line by tedious line to see if they made any sense. And they didn’t. Not then, not now.

Anyway, I digress.

Sentence number 4

“The present back-and-forth between WHO’s critics and defenders previews the coming tussle over how to repair global health governance and reform WHO in light of this disaster”.

I honestly don’t know where to start with this sentence. There is no back and forth, no tussling. “The coming tussle” – can you imagine. It’s hardly ‘the great unravelling’ is it. As under-statements go, it doesn’t quite capture the gravity of the world’s pre-eminent public health organisation fighting for survival.

More importantly, who are WHO’s critics and defenders? How would Fidler describe himself, I wonder? He probably describes himself as “a critical friend”. Trust me, if anyone tells you they’re a critical friend, they’re your enemy. Perhaps Fidler conducted a poll of WHO’s member states and on the basis of that classified them as ‘critics’ and ‘defenders’? More likely he’s just talking about the United States and China, with the U.S ‘the enemy’ and China ‘the friend’? That’s generally how the players are cast these days, with little to no regard to the complexity of politics, diplomacy or international relations. To the extent that WHO receives barely $2bn a year from its member states, you have to wonder whether it has any friends at all.

Having said that, it’s important to remember that WHO represents 194 member states, each one with a voice, each one with a stake in resolving this pandemic, and – I’m prepared to go out on a limb here – most 100% behind WHO. I would argue that what distinguishes the current head of WHO from his predecessors is not the way he praises odious regimes like the U.K, U.S or China – name me a WHO leader that hasn’t done that! No, what distinguishes him is the consideration and respect he shows for all the other – less powerful but no less important – countries of the world. To Tedros, they are his sisters and brothers – a courtesy few other heads of WHO have extended.

Sentence four, of course, is another example of Fidler’s tried-and-tested structure of constructing sentences with clauses that have nothing to do with one another. Demonstrating eminent pre-cognitive skill, Fidler foresees that the back-and-forth “previews” the tussling over how to repair global health governance. I wasn’t aware that the concept of global health governance could be broken, let alone repaired. It’s an aspiration, David, currently in gridlock. But at least we get to end the sentence with a lovely bit of theatre: “in the light of this disaster”. Disaster! Or, alternatively, not a disaster.  

Sentence number 5.

“Although the pandemic is not over, the pillory and praise of WHO are worth exploring now so that the coming tsunami of demands for change do not destroy the organization in order to save it”.

Tsunami (sigh). It’s always a Tsunami, isn’t it. Again, who’s demanding these changes? Most of the demands for change that I’ve heard have been directed at a couple of WHO’s member states by members of the public who are utterly appalled at how little resources are at the disposal of the Organisation. Those demands for change, if heeded, would only strengthen WHO.

Fidler claims to be interested in “the pillory and the praise”, but he’s already done his job in the opening paragraph of this article. He’s primed you before you’ve even started; got you thinking about crises, deep-seated divisions, an uncertain future and the need to change an organisation mired in controversy. Most of you won’t read to the end of the article. How many of you got to half way? But you’ll already have got the sense that there’s something rotten in the heart of Denmark, or rather Geneva. You’ll remember something of the article. Maybe not the detail but an essence. You’ll tell your friends knowingly – oh, I was reading Professor David Fidler’s article on WHO – it’s in deep shit; it’s in crisis; it needs reforming; it’s the end of WHO now, I reckon; there’s a tsunami coming!

This is classic framing. Don’t fall for it. Don’t think of a tsunami!

Are you thinking of a tsunami?

Andrew

One reply on “The World Health Organisation and Pandemic Politics: A reply to David Fidler”

Thanks, I searched for articles I have read (or skimmed) by David F. Found surprisingly few; he hasn’t grabbed me. But he did co-write Moon et al: “Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola. Moon S, Sridhar D, Pate MA, Jha AK … Leigh JA, Hawkins B, Woskie LR, Piot P. Lancet 2015 Nov 28; 386(10009):2204-21.

I was very dissatisfied with that paper mainly for its acceptance of neoliberalism. I reviewed it for Faculty 1000. It’s behind a paywall, but this is what I wrote:

Written by a who’s who of experts in global health and infectious diseases (led by Peter Piot but including, disconcertingly, Chelsea Clinton) this detailed article provides a highly useful analysis of the response to the terrifying outbreak of Ebola in West Africa from December 2013 to November 2015, but with further flares as recently as March 2016 (as I write). The article pulls no punches in criticising WHO. It describes initial complacency not only in West Africa (Guinea where the outbreak started is particularly mentioned) but also at WHO, where the severity of the outbreak was downplayed for several reasons (“leaked internal emails suggest several reasons for the delay including concerns about political opposition from west African leaders, economic ramifications, and a culture within WHO discouraging open debate about sensitive issues, such as emergency declarations”).

WHO indeed deserves censure, as the Director-General (DG) “did not use her International Health Regulation-granted authority to convene the Emergency Committee nor declare a public health emergency of international concern until 5 months after Guinea and Liberia had notified WHO.”

The article notes that the power to declare a public health emergency of international concern vests only in one person (the DG) and recommends the creation of a Standing Emergency Committee that meets regularly, with the mandate to declare such an emergency by a majority vote of its members. Not everything WHO did was bad; it gets praised for “its capacity to lead, convene, coordinate, and establish norms among a broad range of public and private actors on research and development and data sharing .. convene research and development actors .. issue guidance about accelerating regulatory approval of technologies in emergencies.”

The article is also very critical of the lack of financial transparency, both on the donor and recipient’s sides.

However, given that the budget of WHO in 2002 was less than that spent on advertising by two cola companies (Coca Cola and PepsiCo) in 2004 (1) is WHO really so badly to blame? Could there not be broader, more systemic problems of global political culture? There is some recognition of this: “the Global Alert and Response Network’s skeleton staff is too small to deploy in multiple suspected outbreaks, its budget has been severely cut, and it is not authorised by WHO to draw public attention to a crisis.”

Since 2002 the WHO budget may have fallen even more, as evidenced by quotes such as: “in the wake of the global financial crisis (2008) when WHO laid off more than a tenth of its headquarters staff, outbreak response capacity was deeply and disproportionately cut.” “Decades of reducing assessed contributions in real terms has starved the organisation of resources.”

The following extract suggests WHO is in crisis:

“In the wake of Ebola, WHO’s traditional claims of legitimacy based on near-universal state membership no longer seem sufficient. A true recovery will need far greater willingness by member states to entrust resources and delegate authority to WHO, but it has rarely been in a weaker position to command such trust and authority. Confidence in the organisation’s capacity to lead is at an all-time low. Calling for additional staff or a larger budget will not address this. WHO must find a way to prioritise what it does, and regain its credibility, independence, and legitimacy to perform its core functions. Breaking out of this 20-year impasse will demand clear commitment and a different kind of leadership by WHO to implement fundamental reforms under a tight timeline, matched by an equally clear commitment by member states to reward such reform with appropriate authority and resources. WHO performed a key coordinating function in research and development during the Ebola epidemic. It was also central to controlling nine previous Ebola outbreaks, SARS, and other epidemics. These examples are important reminders of what WHO can do under determined leadership. WHO is in a formal reform process that was spurred by a budget crisis in 2011; in some ways, it has been in a perennial process of reform since at least the 1990s. These previous efforts are a reminder that high-level political leadership, such as the engagement of heads of state, will be needed if the outcome is to be different this time. At this point, anything less than fundamental reform will mean continued marginalisation and decline, alongside increasing vulnerability for global public health.”

The article includes extensive recommendations for how WHO might be strengthened, mainly by narrowing its focus and trying to wrest a different form of funding.

The first recommendation of the paper is develop a global strategy to invest in, monitor, and sustain national core [health] capacities. However, the onus seems then to be largely placed on WHO to do this (“WHO should convene governments and other major stakeholders within 6 months to begin developing a clear global strategy to ensure that governments invest domestically in building core capacities and to mobilise adequate external support to supplement efforts in poorer countries.”)

True, the article does note “growing momentum in the wake of Ebola for such investments: the US Government has committed $1 billion to build core capacities in at least 30 developing countries, including Guinea, Liberia, and Sierra Leone.” But it is easy to make such promises. Elsewhere the article notes long gaps between pledges and delivery.

However, the broader challenge of promoting development in low-income settings appears to have been overlooked in this paper. Firefighters are needed, but so is fire prevention. WHO cannot do everything.

Neoliberalism (not mentioned in the article) needs to be challenged. The closest mention to a criticism of market-based economies is in Recommendation 7: (“funders should establish a worldwide research and development financing facility for outbreak-relevant drugs, vaccines, diagnostics, and non-pharmaceutical supplies (such as personal protective equipment) when commercial incentives are not appropriate”).

There seems little if any recognition that market forces, untrammelled, combined with laissez-faire, environmental policies and population growth could generate the milieux in which Ebola and other pandemics thrive (2). This blindspot is also evident in a paper written by Bill Gates cited in this (3). Nor is there any hint that the stress on vertical health programmes warrants reconsideration (4).

Referenced works:

1. Lang, T.; Rayner, G.; E., K. The food industry, diet, physical activity and health: A review of reported commitments and practice of 25 of the world’s largest food companies. Report to the World Health Organization; City University Centre for Food Policy, London UK: 2006.
2. Infectious disease emergence and global change: thinking systemically in a shrinking world. Butler CD. Infect Dis Poverty. 2012; 1(1):5 PMID: 23849217 DOI: 10.1186/2049-9957-1-5
3. The next epidemic–lessons from Ebola. Gates B. N Engl J Med. 2015 Apr 9; 372(15):1381-4 PMID: 25853741 DOI: 10.1056/NEJMp1502918
4. Beyond Ebola: a new agenda for resilient health systems. Kieny MP, Dovlo D. Lancet. 2015 Jan 10; 385(9963):91-2 PMID: 25706456 DOI: 10.1016/S0140-6736(14)62479-X

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