“Talking about this generation” The need for a new WHO..

Just as the Covid crisis in this country makes us look at our social structures and institutions so, because this is a world pandemic, we need to also think about how the World Health Organisation has worked and needs to work in the future.

What, in the third decade of the 21st century and given current issues surrounding world governance, is likely or possible?

I’ve had a few friends who have worked for the UN in human rights and peacekeeping. They did not find it an easy experience. There seems to be an even bigger gap between moral promise and reality than in most organisations.

The moral promise – post the awful slaughter of the Second World War – started as a history changing possibility. In the 1960s I was growing into politics with strong sympathies for the potential of international governance. My generation saw a clear case for nations needing some governance above them to stop them from acting very badly.

But even by the late 60s, with the British in Suez, the USSR in Hungary and the USA in Vietnam it was clear that the UN could not stop the governments of larger countries from carrying out rule-breaking invasion activities if they wanted. For very big things it was ineffective.

But on those major issues in which the big powers did not have a passionate interest, there were important activities. And there were countless conflicts that stopped short of war because the UN provided a place to talk. It kept bits of the peace.

As an organisation, as it tried to act in the interstices of the cold war, it needed to develop as much consensus as possible to act at all. Consensus building became the norm for even the smallest actions. Given the weakness of international governance this consensus was important, but to achieve it the UN had to develop layers of bureaucracy. This not only made swift action difficult, but day-to-day operations were overlaid by these levels of bureaucracy.

I’ve gone into some detail about the UN because the meaning and structure of the WHO (founded in 1948) is so much a part of the post-war international settlement. Remember that the worst 20th century pandemic, Spanish flu, followed the First World War and the likelihood of something similar taking place in an exhausted world with exhausted bodies after World War Two was worrying.

There were some who wanted the WHO to be an organisation that could enforce worldwide rules of health. They wanted there to be sanctions if these rules were not complied with. This never happened. In fact thinking about it, how, in 1950,  countries with developed health care systems could have  FORCED countries without them to implement health care is a puzzle.

The ability to enforce its edicts never happened with the UN – and it never happened with the WHO. The governance structure was based upon a whole set of interventions which were not enforceable.

Imagine for a minute (and it’s a big stretch of the imagination) that on January 31st this year when the pandemic was named by WHO, they had been able to TELL the British Government what to do. This is how you continue test, track and trace and you have to do it this way. Now you must lockdown. (I know, I know, it would have been helpful if we had all been honest and WHO could have increased our testing capacity in February and March). It’s a fantasy. Nations are too strong. International governance much too weak.

The problem for the world is that whilst Sierra Leone will accept interventions and the structure of government which helps it fight Ebola – many developed countries will see that not as being helpful but as interference.

This is the important issue for then and now.

The problem of pandemics in 1948 and today are clear. For centuries even the limited trade and interaction of the Middle Ages demonstrated that infections did not respect borders – or oceans. When WHO was set up the world was built on much greater trade and much greater movement of peoples.

Since then new forms of globalisation has meant that the spread of a pandemic moves much faster. There is now virtual certainty that if an infection can pass from human to human global trade and movement of people will ensure the infection travels from country to country.

The last few years have seen a counter trend to globalisation which is the increased power of nationalism. An era of powerful nationalism is a very difficult one in which  to build stronger international governance. If it was not possible in 1948 – after a savage and destructive war – to build international organisations with powers of enforcement, let’s face it, it will not happen now

Currently this nationalism may appear to be strongest and most destructive in the USA. But not only is there our own British exceptionalism (“who needs the rest of the world when we have world-beating everythings”). There are also very loud and increasingly powerful nationalist China Russia and India.

Now, in 2020, is the time when most of the world’s understanding about the impact of pandemics is at its very strongest. Now is the time to make the case about the limitations of nationalism. If you had told the world that global GDP would go down by 3% [1] in 2020 because of a pandemic, nations would not have believed it possible. If you had said to the NHS that they would spend £14 billion [2] on PPE in 2020 they wold have not believed that possible either.

I am not a starry-eyed optimist and do not expect Trump, Johnson, Xi, Modi and Putin to simply give up money and power to an international body to stop this from happening again. Most of the leaders on that list still believe that their country is capable of looking after itself without outside help.

So I don’t think a new WHO will be swamped with money and powers by them. My suggestion is limited by national political realities. However I do think that in each of these countries there are many epidemiologists and population health managers who have learnt how to limit the impact of epidemics on nations. Today, we know more detail about how to do this and what works in different social structures than we have ever done before.

Mainly this knowledge exists within each country. For example in England, from this week if you want to share national and local data for test, track and trace (who would have thought of that?), we now know that it is probably a good idea to agree protocols for data sharing at the beginning of the pandemic.

Each country’s epidemiologists could draw up 5 good and 5 bad lessons from their national experience so far. WHO needs to help collate and consolidate this knowledge, and whilst doing so recognise that cultural and political diversities in each country will need very different applications.

I am not sure the national governments of the world are up to any expansion of the  international governance of pandemics.

But I am very sure that national scientists of each country would want to contribute internationally. Within some nations, because governments may not be enthusiastic about alternative views to their own, this may be tricky but WHO would have to provide some cover.

So I am not really suggesting a new WHO. I don’t think these nationalist times are the best placed for that. But I do think – in 2020 – that more public health scientists think internationally about pandemics and could consequently develop much better work internationally.

These ideas would still need to be sold to a series of nationalist nations. But we should at least have something to sell.

More on WHO later in the week.

[1] IMF estimate 02/07/2020

[2] HSJ estimate 02/07/2020