Should the USA pull out of the World Health Organization?
It is widely reported that one of the first acts of the incoming Trump administration will be to withdraw from the World Health Organization (WHO). Predictably, responses are divided. US nationalists dislike the growing efforts to turn WHO into some form of world government with authority to dictate health policies to individual states. Against this, a significant element of the biomedical establishment, whether from public health, clinical medicine or allied professional, scientific and social scientific disciplines, are clearly unhappy about the subordination of their expert views of health matters to those of elected politicians. These disagreements have been brought into sharp focus by the attempt to redefine WHO’s role and powers in the wake of the Covid-19 pandemic. Is this a dangerous move towards the creation of a cosmopolitan iatrocracy, rule by a rootless caste of biomedical technocrats, or a necessary precaution against some future pandemic that presents a genuinely existential threat to humanity?
As in other areas, national and international responses to the Covid pandemic have disrupted traditional political alignments and created unlikely alliances. WHO is no different. There is an excellent recent history (Cueto et al 2019), which shows how the organization was founded after World War II as a successor to various international bodies that had collated and shared data and expertise in public health and epidemiology. From the start, however, there was a tension between two very different visions. One was a social science view of public health, which understood epidemic disease as a societal challenge, requiring a broad, horizontal and multi-sectoral response. The other was a technocratic, biomedical view that favoured narrowly-targeted, vertical interventions, delivering scientific medicine to naïve populations.
Initially, WHO was dominated by the US and other developed countries, acting on behalf of their empires, and favouring technocratic approaches. Decolonization shifted the balance of power towards developing nations, who were reluctant to accept directives from their former overlords. This was reflected in the community-oriented strategies adopted by the smallpox eradication campaign and a growing emphasis on primary health care rather than high technology interventions. The major funders were unenthusiastic about this shift, though, especially as there were also growing concerns in the 1980s and 1990s about poor leadership, corruption and the lack of effective co-ordination between different parts of the organization. With states reluctant to maintain or increase funding, WHO looked for new sources of income and found them in bodies like the World Bank and the Gates Foundation. These reinforced technocratic approaches, defining top-down targets to be achieved through time-limited programmes. The Gates Foundation, in particular, is notorious for its belief that there is a technical fix for every social problem. While this model was already in trouble, as a result of the failures of the response to the Ebola outbreak in West Africa in 2014-2016, its influence was secured by the financial importance to WHO of its adherents and the hollowing-out of capacity to engage with the social sciences.
https://www.socialsciencespace.com/2014/10/ebola-whats-the-point-of-the-world-health-organisation/,
https://www.socialsciencespace.com/2014/12/ebola-the-human-cost-of-neglecting-the-social-sciences/
https://www.socialsciencespace.com/2015/07/ebola-who-and-the-consequences-of-ignoring-social-science/
The Covid-19 pandemic offered an opportunity for a reset. The WHO’s charter, after all, recognizes that ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. There is more to a good life than the minimization of mortality and morbidity. However, like many other actors, WHO failed to acknowledge that pandemics are a societal challenge not a purely medical one. The management of mortality from one cause cannot be achieved without an understanding of the opportunity costs. These include deaths from other causes because of the disruption of health services, ‘deaths of despair’ from the accentuation of poverty and social inequalities in technocratic responses, and the loss of other things that might be of value, such as autonomy, choice and liberty in the conduct of personal affairs. A meaningful life is not just the avoidance of death.
This reset has not happened. Rather, we have seen a doubling down on the assertion of biomedical power. That is not, in itself, unexpected. Public health leaders have long reached for law to impose their policy preferences, where a population is insufficiently persuaded to comply voluntarily. If the social sciences are to be admitted to debates, it is on technocratic terms. WHO engages behavioral scientists to secure the compliance of populations rather than social scientists who might question the goal itself. Health lawyers and ethicists with long and distinguished records of respect for patient autonomy are enlisted to supply justifications for population control. For some, it clearly represents a way to resist Trumpian values without the messiness of a political process. Key societal decisions can be shifted into an international forum of like-minded people, avoiding the hard labour of winning hearts and minds in a democratic state.
The danger of a US withdrawal under a Trump administration is that it makes the problems with WHO seem to be all about MAGA. Withdrawal would certainly damage WHO functions from which the US itself benefits, in terms of a clearing house for information and an opportunity to exercise soft power through the supply of expertise. However, it also leaves the remaining members free to go their own way and create an international pandemic governance system based on the same limited vision of a good society. The fundamental issues of societal accountability need not be confronted. The World Health Assembly does not pass this test. It is a convention dominated by health ministries rather than government units with responsibilities to consider the overall costs and benefits of pandemic interventions. The Director-General’s recommendation that a pandemic be declared and exceptional powers invoked is like presenting hymn sheets to the choir. The UN Security Council and General Assembly have many limitations but they are the bodies representative of whole societies that should shape responses to global threats.
Maybe the US price for continuing WHO membership should be reform that blocks the aspirations to iatrocracy but retains the organization as an important technical, advisory and monitoring body. Political accountability would properly be located with governments that could take a ‘whole of society view’ rather than focussed on the narrow thinking of a biomedical elite and its allies.
