Anders Nordström is a busy little bee, isn’t he. His output in 2026 has been, how might one put it, excessive. February was just the start. You’ll recall, I’m sure, his classic Comment in The Lancet Four paradigm shifts to shape an agenda for global health reforms – an article that had nothing to do with actual Kuhnian paradigm shifts and everything to do with painting the status quo a slightly different colour. Then, in April, we had a second Comment in The Lancet A WHO worth fighting for: the case for focused, ambitious reform which was all about ambition – Nordström’s. April saw the first of what will be – one fears – many contributions to ThinkGlobalHealth No One Wins If Multilateralism for Health Loses in which Nordström outlines his plan for ensuring that everyone comes round to his way of thinking or, as he likes to call it, a “shared vision” of “a simpler, more focused, and more legitimate international system for health”. And now we have this just-published piece for ThinkGlobalHealth Reforming WHO: Five Considerations for the Next Director General. It would be easy to write a post on each of his five considerations but that would be painful to read. So, I’m going to focus on consideration #1 – WHO’s operational logistics.
People like Nordström have long argued against the WHO being active in the field. Here is how Nordström reworks this tired observation: “[WHO] should not become an operational logistics agency competing with others for visibility, emergency supplies, or field leadership. Once WHO drifts too far into operational competition, it risks weakening precisely the role that it alone can play”.
It’s always important to focus on language. Do you see what Nordström is doing in that final sentence? “Once”, “drifts”, “too far” and “competition” are all words designed to cast operational support in a negative light without it appearing that that is what he is doing. “Once” implies the start of the point of no return, and so should be avoided lest WHO’s operational designs get the better of it; “drifts” implies a ship without a rudder and thus out of control; “too far” is Nordström’s attempt at managing expectations – he can say ‘I’m not saying WHO shouldn’t be involved, just that it should be involved on my terms’; and “competition” – while it can be a positive thing – here means inefficient use of resources. There is no competition, of course, but let’s return to that in a minute.
There are MANY ways to counter Nordström’s argument about operational logistics. To start with, the WHO is an operational logistics agency, so it’s too late for him to be saying that the Organisation “shouldn’t become one”. Article 2d of WHO’s Constitution states that one of its functions is to “…furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of Governments”. And article 2 also authorises WHO to: “establish and maintain effective collaboration with governmental health administrations”, “stimulate and advance work to eradicate epidemic, endemic and other diseases”, “assist Governments, upon request, in strengthening health services”, “promote maternal and child health and welfare and to foster the ability to live harmoniously in a changing total environment”, and “report on, in co-operation with other specialised agencies where necessary, administrative and social techniques affecting public health and medical care”. It’s hard to see how the WHO could fulfil these functions adequately by sitting behind a desk. But Nordström wants to row the Organisation back to a better time, a time when WHO didn’t concern itself with field work. In other words, a period in WHO’s history that only exists in his head, not reality.
Consider some of the WHO’s most important work: Smallpox eradication – WHO coordinated one of the largest operational health campaigns in history; Polio eradication – WHO continues to coordinate massive vaccination operations; HIV/AIDS – WHO developed treatment guidelines and procured medicines, trained staff and supported implementation; Covid-19 – during the pandemic the WHO shipped PPE, coordinated supply chains, established logistics hubs, distributed diagnostics, supported oxygen delivery, and trained clinical teams. All of these are operational functions. Since 2016, the WHO has operated a Health Emergencies Programme. Not because it unilaterally decided it should but because Member States concluded after the 2014 Ebola outbreak that WHO needed stronger operational capability. The HEP now deploys epidemiologists, logisticians, emergency coordinators, laboratories, and supply chains whenever and wherever they are needed.
One age-old repost can be summarised in four words: lead-from-the-front. Or, if you prefer: get-your-hands-dirty. There’s a reason why General Maximus Decimus Meridius was loved by his troops and wannabe Roman Emperor Commodus wasn’t – it’s because he was there, in the field, with them. There’s a scene in the film Gladiator where Commodus rides into battle too late. “Have I missed it? Have I missed the battle” he asks, feigning concern. “You have missed the war” replies his father. I could just leave it there – it’s an obvious point, after all. But to be clear, it’s crucial to WHO to be seen as legitimate in order for it to maintain authority, and a good way to do that is by ‘being present’ and capable in its operational support. Visibility is crucial, so WHO shouldn’t – to extend the gladiator metaphor further – become an armchair general. Nobody respects them. Easy to say and don’t take my word for it. Instead, read this all-too-short account of a day in the life of WHO’s Ebola Community Engagement Officer Julienne Anoko. The title is really important – At the Frontline of Trust – and I’ve copied a paragraph from it below. It illustrates some of the gazillion reasons why WHO staff need to be ‘in the field’.
By 7:30 a.m., Julienne joins WHO’s morning stand-up meeting, where the different pillars of the Ebola response come together: surveillance, infection prevention and control, laboratory teams, coordination, protection from sexual exploitation and abuse, psychosocial support, human resources and case management. Her role is to bring the community into the room — sharing insights from the community—such as misinformation, resistance, or concerns—and help align engagement strategies with the latest outbreak data. This ensures that messaging is both accurate and responsive to community realities.
But this is what Nordström simply doesn’t get. Take this tortured sentence, for example: “WHO can only reclaim trust by becoming unquestionably excellent at what it is uniquely positioned to do”, which in his mind is its normative and technical work.
Wrong. The WHO won’t ‘reclaim trust’ by focusing on just those functions. If it did, the rest of the world would be less likely to take it seriously. Over time, stay-at-home Emperor Commodus’ conspirators first tried to poison him.Then, when the poison failed, they summoned his wrestling partner, Narcissus, who strangled him in his bath. Expect a similar fate for the WHO if its next Director General takes Nordstrom seriously.
Wrong. Claims that WHO has lost trust is deliberately exaggerated by Nordström et al because it suits their agenda. But just so we’re clear, WHO hasn’t lost much trust amongst its Member States. Some, yes, but only the psycho-violent ones. So the Organisation doesn’t need to ‘reclaim’ it.
Wrong. WHO is not just “uniquely positioned” to provide normative and technical support. It seems to be pretty good at emergencies work too. If we look at what it has done to respond to the current Ebola outbreak, WHO has done all the usual normative and technical stuff: declaring a PHEIC, issuing technical guidance, coordinating international surveillance, convening expert groups, providing lab protocols, and deployed the usual suspects to and in country (epidemiologists, infection prevention specialists, laboratory experts, logisticians, risk communication specialists, etc). But WHO has also: assisted clinical trials of experimental antivirals, flown emergency medical supplies into DRC and Uganda, established treatment capacity, supported laboratories, helped coordinate contact tracing, and supported cross-border surveillance. This is classic operational support, and WHO is very good at it. It’s just not being funded sufficiently to do its job.
Wrong. You can’t separate operational functions from normative and technical functions. Modern outbreak control is not simply about writing guidance: guidance without implementation is ineffective. WHO can recommend the things it regularly recommends: isolation, contact tracing, PPE, lab work. But who’s going to coordinate delivery? WHO can do that but it needs to be there to do that effectively, ‘mucking in’ so to speak. Implementation generates credibility; operational capacity enables normative authority – I read that on a t-shirt so it must be true.
And wrong. Nordström describes WHO and Africa CDC announcing aid within hours of each other as evidence of unhealthy institutional competition. But there’s no evidence of ‘competition’. As noted above, this is just a rhetorical ruse to get you thinking that there are too many cooks spoiling the global health governance broth. Elsewhere, Nordström waxes lyrically about subsidiarity but, as is par for the course, appears to misunderstand and misapply the concept. A better way to think about what is going on is not competition but redundancy, with the central insight being that more cooks make for a more resilient service delivery – the broth will be served even if one of the cooks has a Gordon Ramsey-esque meltdown in the kitchen. Or, if you don’t like cookery metaphors, redundancy simply means “the ability to reserve some resources for use if disruptions occur“. It makes intuitive sense – have multiple institutions primed and ready to go in case one fails. It’s pretty common practice in other systems – air traffic and power grids, for example – so why not global health emergencies?
Talking of air traffic control, for as long as I can remember the actors that perform the global health governance function have been ‘flying in crowded air space’, to recall Ruairi Brugha’s memorable phrase. The final sentence of his 2005 Editorial seems prescient twenty years later: “It would be simpler for countries if the global community puts its development assistance into fewer vehicles that demonstrate they are willing and able to co-ordinate”. Here, I would argue for a return to greater coordination between national governments and regional and international organisations, not less. This is after all what they’re good at – coordinating. If there’s going be a ‘global health leap‘, then by all means let it be the partnerships first, followed by the Trusts and the Foundations. Like Nishtar, I hope for a day when we don’t need GAVI, the Alliance formally known as The Gavi Alliance (or whatever it calls itself these days) or the Global Fund, or Welcome, the Trust formally knows as The Welcome Trust, or the Epstein Appreciation Foundation formally knows as the Gates Foundation. Give the air traffic controllers a bit of air space back and see how that works before clipping the wings of important global health actors like the WHO. Give it the funding it needs so it can flourish. Fragmentation is a problem, I get that. But reducing WHO’s operational role could leave even more coordination gaps unless another actor assumes those responsibilities – and we all know who is waiting in the wings to do that.
Andrew
