46 Scientific American, March 2022
Global
Health
Institutions
Reached
Their Limits
The need to reinvent the
World Health Organization
has become abundantly clearBy Lawrence O. Gostin
M
oments of existential crisis can turn into
opportunities for bold reform. World
War II led to the creation of trans form a
tive institutions—the United Nations in 1945 and
the World Health Organization in 1948. The birth
of the WHO came the same year that the U.N. ad
opted the Universal Declaration of Human Rights.
The COVID pandemic marks just such a mo
ment of crisis. But instead of ushering in signifi
cant change, it has fractured global solidarity. That,
in turn, has revealed deepseated fragility in the
WHO, the planet’s health leader. The WHO’s bind
ing, governing framework for pandemic response—
the International Health Regulations—has failed to
serve its purpose in the face of widespread failures
by national governments to comply.
But it is not too late to turn the corner. In fact,
this is just the moment to ask what a bold new
global public health architecture might look like.
As the U.N.’s first specialized agency, the WHO
has a constitutional mandate to direct and coordi
nate international health, which includes advanc
ing work to eradicate epidemic disease. No state
acting alone can prevent the worldwide spread
of infectious diseases. Only robust international
institutions can set global norms, promote cooper
ation and share scientific information needed to
respond to disease outbreaks. As a result, the
WHO’s role remains indispensable. With vast and
growing global interdependency, intercontinental
travel and mass migration, the realities of global
ization and climate change have fueled a modern
era of new diseases. The list includes three novel
coronaviruses—SARSCoV, MERSCoV and SARS
CoV2—and, of course, Ebola and Zika.
WHO director general Tedros Adhanom Ghebrey es us has been the world’s conscience throughout
the COVID crisis by urging global cooperation. But his
pleas have largely been ignored by nationalistic lead
ers taking a stance of “my country first.” Global dys
function reached a pinnacle when President Donald
Trump formally announced the U.S.’s intent to with
draw from the WHO. (President Joe Biden reversed
this decision on his first day in office.) Yet Trump’s was
only one of many dysfunctional nationalistic respons
es, which ranged from neartotal border closures to
the hoarding by rich countries of personal protective
equipment, oxygen and vaccines. The WHO was pow
erless to stop any of it. Even the agency’s vaunted sci
entific expertise came into question, as it was embar
rassingly late in recommending masks or acknowledg
ing asymptomatic and aerosolized spread of the virus.
It is tempting to simply create an entirely new in
ternational health organization, but that would be a
serious mistake. It took a world war to build political
consensus to establish a global health agency with
vast constitutional powers. Every country on Earth is
a member except Liechtenstein and Taiwan (the latter
left out because of the U.N.’s “One China” policy). The
WHO helped to lead the efforts that brought about
the eradication of smallpox and the near eradication
of polio, among other crowning achievements. In
stead of giving up on the agency, we should use this
moment, and what political consensus we have, to
prepare the organization for future pandemics—and
what remains of the current one. This goal can be ac
complished with robust funding and a bold new in
ternational agreement.
It has become painfully obvious that there is a ma
jor disconnect between what the world expects of the
WHO and its capacities and powers. Consider its fund
ing: The WHO’s next Biennium Budget (for 2022 and
2023) is $6.12 billion, less than those of some large U.S.
teaching hospitals and one fifth of the budget of the
Centers for Disease Control and Prevention. As long
ago as 2011, the WHO’s report on the H1N1 influenza
pandemic concluded that the agency’s budget is “whol
ly incommensurate” with its global responsibilities. Yet
the money it receives has remained roughly constant in
inflationadjusted dollars for the past three decades.
What is worse is that the WHO has control of less
than 20 percent of its overall finances. That is the per
centage of its budget that comes from socalled man
datory assessed contributions. The rest consists of
voluntary contributions, which are mostly earmarked
for donors’ pet projects. The WHO cannot set global
priorities or even hire for the long term, as voluntary
funds disappear after a year. A donor then may just
shift to another cause. Sustainable funding requires,
at minimum, doubling the WHO’s total budget over
five years, with mandatory assessments making up at
least 50 percent of its overall budget. Yet even these
modest proposals might not pass muster, because
member states insist on calling the shots as to how
their contributions are used.