Op-ed: Can public health and politics be balanced in the WHO?

I will start off by stating that I disagree with Trump’s decision to withdraw American funding from the World Health Organization (WHO). I believe the world must be united in combating COVID-19. However, I want to provide some context on the current director-general of the WHO, Dr. Tedros Adhanom, and how he and the WHO have made certain missteps in responding to the COVID-19 pandemic.

In 2017, I was living in Ethiopia and was about to graduate from high school.

In March of that year, The New York Times reported that there was a cholera outbreak in Somalia, which shares a long border with Ethiopia, that infected over 13,000 people. According to the WHO, cholera “is an acute diarrhoeal disease that can kill within hours if left untreated.” To combat this, the country embarked on a new vaccine program against cholera.

That same spring, there was an outbreak of Acute Watery Diarrhea (AWD) in Ethiopia. According to The Washington Post, by May 2017, 16,000 were infected and 3,500 new cases were appearing each month in the Somali region of eastern Ethiopia. Aid officials believed that cholera was circulating throughout the country, but because the Ethiopian health ministry was still calling it AWD, they could not deploy the vaccine. 

The WHO was also closely monitoring the situation in Ethiopia. They “complained privately” that the Ethiopian government was not telling the truth about these outbreaks, given that testing was relatively simple and took less than two days to complete

Ultimately, despite international pressure, the Ethiopian government was not willing to take the next step and acknowledge the cholera epidemic

During this time, Dr. Tedros Adhanom, an Ethiopian national and the country’s former minister of health from 2005–2012, was a strong candidate” to be director-general of the WHO. Dr. Tedros was no longer a part of the Ethiopian government after 2016, so the country’s 2017 AWD outbreak was not necessarily his responsibility. However, in 2006, 2009 and 2011, during Dr. Tedros’ time as health minister, there were similar outbreaks of AWD in Ethiopia, “in which cholera bacteria were found in stool samples tested by outside experts.” Further raising speculation, as soon as cases of severe diarrhea appeared in neighboring countries, they were also identified as cholera

In an article on the accusations held against Dr. Tedros Adhanom by global health expert Dr. David Nabarro, The New York Times highlighted that the case of Ethiopia was not unique. 

“Historically, some countries have tried to cover up or play down outbreaks of human or animal diseases for fear that travel restrictions would be imposed, tourism would suffer or food exports would be curtailed,” the article states. 

According to the International Health Regulations outlined by the WHO, state parties can screen imports, such as cargo and goods, “when coming from infected areas and when the health authority has reason to believe that the cargo and goods may have become contaminated … or may serve as a vehicle for the spread of any such disease.” The WHO urges countries not to apply these restrictions, but they also ask for member nations to immediately report outbreaks of cholera, which Ethiopia failed to do.

On its website, the WHO states that it strives for “universal health coverage,” with one of its main methods of achieving this goal being the improvement of “monitoring, data and information.” Another one of its objectives is to “detect and respond to acute health emergencies.” Dr. Tedros did not appear to abide by these standards appropriately during the AWD outbreaks in Ethiopia. Instead of identifying the bacteria as cholera and immediately reporting cases to the WHO, he accepted the watered-down label of AWD, and there is a reason for it.

He is a public health official, but he is also a politician. When it came to the country’s decisions on AWD and cholera, political and economic interests outweighed public health goals, and Dr. Tedros failed to comply with the International Health Regulations. Also worth noting is Dr. Tedros’ membership to the Tigray People’s Liberation Front (TPLF), one of the ruling political parties of Ethiopia until 2019. He was also Ethiopia’s foreign minister from 2012–2016.

Now, as the head of the WHO, he faces those who may not have wanted the declaration of a global pandemic perhaps for the similar reasons of avoiding travel restrictions and potential negative effects on tourism and exports.

A telling example of this is the WHO’s interactions with China toward the beginning of the spread of COVID-19. Until Dr. Tedros visited President Xi Jinping at the end of January, the “WHO was uncritically repeating information from the Chinese authorities, ignoring warnings from Taiwanese doctors — unrepresented in WHO, which is a United Nations body — and reluctant to declare a ‘public health emergency of international concern,’ denying after a meeting Jan. 22 that there was any need to do so.” 

China’s political and economic interests here were clear; no country wants trade or travel restrictions to be imposed on it. Eventually, the WHO was able to send its own experts to China to make its own appraisal, but it took time.

Another question that should be investigated is how the WHO decided to declare a pandemic. COVID-19 was only declared a pandemic on March 11, once it was already present in 114 countries and in multiple WHO regions.

After the 2009 H1N1 swine flu was quickly contained after being declared a pandemic, there was a prevailing view that the announcement of a pandemic overstated the actual danger of the virus. As a result, “the [WHO] gave up its old definition of a pandemic: ‘sustained human-to-human transmission of a novel pathogen in two or more [WHO] regions.'”

Indeed, Director-General Dr. Tedros warned the public on Feb. 24 of the dangers of declaring the outbreak of COVID-19 a pandemic. “Using the word pandemic now does not fit the facts, but it may certainly cause fear,” he said.

The WHO is not an independent organization; it is made up of many member states who each have a stake in its decisions. As shown by the Ethiopian response to AWD, we know that countries can choose to understate facts in order to support their political and economic interests. 

How can the WHO remain objective when deciding to declare a pandemic if there is no strict definition of one and doing so goes against the political interests of its member states?

We know declaring a pandemic has significant economic implications for the WHO’s member states, but it also galvanizes states to step up public health measures in order to prevent an even worse outcome. Balancing public health with political and economic interests is very difficult, as shown by the former Ethiopian health minister’s track record with cholera. Yet, the WHO exists as an institution whose mandate requires prioritizing public health over political and economic interests.

Consequently, I believe the WHO should bear some responsibility for the unpreparedness of the world when facing COVID-19, as should some of its member states, who have interests separate from public health.

Right now is not the time to withdraw funding and completely distance ourselves from the WHO. We need to work together to fight COVID-19, and once the pandemic subsides, we can find out with more clarity what went wrong when the WHO tried to balance politics and public health.